=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447411863
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRUPO CLINICO DEL NORTE CSP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2008
-----------------------------------------------------
Last Update Date | 06/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR 693 KM 14.7 SECTOR BRENAS LABORATON CLINIC SAN VICENTE V
-----------------------------------------------------
City | VEGA ALTA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00692
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-915-7700
-----------------------------------------------------
Fax | 787-915-7700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | BOX 3244 LABORATON CLINICO SAN VICENTE V
-----------------------------------------------------
City | MANATI
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00674
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-915-7700
-----------------------------------------------------
Fax | 787-915-7700
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BSMT SUPERVISOR
-----------------------------------------------------
Name | MILAGROS GONZALEZ
-----------------------------------------------------
Credential | MT
-----------------------------------------------------
Telephone | 787-447-8484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 1124
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------