Healthcare Provider Details

I. General information

NPI: 1154603546
Provider Name (Legal Business Name): WAXALI INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RIO DEL PLATA MALL,URB JARDINES DE TOA ALTA,CALLE # 1 SUITE # 8
TOA ALTA PR
00953
US

IV. Provider business mailing address

HC 72 BOX 3954
NARANJITO PR
00719-8771
US

V. Phone/Fax

Practice location:
  • Phone: 787-545-3200
  • Fax: 787-545-3201
Mailing address:
  • Phone: 787-869-1111
  • Fax: 787-869-2318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number1248
License Number StatePR

VIII. Authorized Official

Name: MR. JOSE L COLLAZO-ROSADO
Title or Position: PRESIDENT
Credential: MT
Phone: 787-869-1111