Healthcare Provider Details

I. General information

NPI: 1164563243
Provider Name (Legal Business Name): PONCE CLINICAL LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 TITO CASTRO AVE SUITE 101
PONCE PR
00716
US

IV. Provider business mailing address

609 TITO CASTRO AVE SUITE 101
PONCE PR
00716
US

V. Phone/Fax

Practice location:
  • Phone: 787-841-4846
  • Fax: 787-841-4846
Mailing address:
  • Phone: 787-841-4846
  • Fax: 787-841-4846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number273
License Number StatePR

VIII. Authorized Official

Name: MRS. GRYCEL ROSADO SANTIAGO
Title or Position: OWNER
Credential: M.T.
Phone: 787-841-4846