=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477978450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESTLYAN LAB, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2014
-----------------------------------------------------
Last Update Date | 05/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CALLE GUILLERMO RIEFKOHL NUM. 8
-----------------------------------------------------
City | PATILLAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-271-6602
-----------------------------------------------------
Fax | 787-271-6544
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | F2 CALLE C
-----------------------------------------------------
City | YABUCOA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00767-3209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-685-8486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JUAN FRANCISCO ROSARIO
-----------------------------------------------------
Credential | MT
-----------------------------------------------------
Telephone | 787-271-6602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 1311
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------