=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497716864
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VELEZ DE JESUS LABORATORIES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 72A CALLE BALDORIOTY
-----------------------------------------------------
City | VEGA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00693-4337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-858-1014
-----------------------------------------------------
Fax | 787-858-1014
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4155
-----------------------------------------------------
City | VEGA BAJA
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00694-4155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-858-1014
-----------------------------------------------------
Fax | 787-858-1014
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CARLOS W VELEZ SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-692-1705
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 390
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------