Healthcare Provider Details

I. General information

NPI: 1922094473
Provider Name (Legal Business Name): LABORATORIO CLINICO AQUARIUM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARR 165 KM 4.7 PLAZA AQUARIUM SHOPPING MALL
TOA ALTA PR
00953-8836
US

IV. Provider business mailing address

PO BOX 970
DORADO PR
00646
US

V. Phone/Fax

Practice location:
  • Phone: 787-870-2101
  • Fax: 787-870-2101
Mailing address:
  • Phone: 787-870-2101
  • Fax: 787-870-4077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number957
License Number StatePR

VIII. Authorized Official

Name: MRS. JOLLY ORTIZ
Title or Position: DIRECTOR
Credential: MT
Phone: 787-614-2131