Healthcare Provider Details

I. General information

NPI: 1154308674
Provider Name (Legal Business Name): LABORATORIO CLINICO COUNTRY CLUB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

#758 AVE CAMPO RICO COUNTRY CLUB
SAN JUAN PR
00924
US

IV. Provider business mailing address

1353 CARR. #19 PMB #364
GUAYNABO PR
00966-2701
US

V. Phone/Fax

Practice location:
  • Phone: 787-750-0510
  • Fax: 787-257-1110
Mailing address:
  • Phone: 787-750-0510
  • Fax: 787-257-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number147
License Number StatePR

VIII. Authorized Official

Name: EDWIN CARDONA
Title or Position: OWNER
Credential: MT
Phone: 787-748-4102