=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396998019
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LABORATORIO CLINICO SANTA OLAYA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2008
-----------------------------------------------------
Last Update Date | 10/25/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR. PR 829 KM 6.2 SANTA OLAYA
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PUERTO RICO
-----------------------------------------------------
Zip | 00956
-----------------------------------------------------
Country | UM
-----------------------------------------------------
Telephone | 787-466-2052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 374
-----------------------------------------------------
City | BAYAMON
-----------------------------------------------------
State | PUERTO RICO
-----------------------------------------------------
Zip | 00960
-----------------------------------------------------
Country | UM
-----------------------------------------------------
Telephone | 787-466-2052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JORGE DAVID RIVERA
-----------------------------------------------------
Credential | J.D.R.
-----------------------------------------------------
Telephone | 787-466-2052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------