=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518133628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LABORATORIO CLINICO LOS ANGELES MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2008
-----------------------------------------------------
Last Update Date | 08/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 CALLE SAN RAFAEL SUITE 203
-----------------------------------------------------
City | SANTURCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00909-2693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-721-6626
-----------------------------------------------------
Fax | 787-725-1287
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 CALLE SAN RAFAEL SUITE 203
-----------------------------------------------------
City | SANTURCE
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00909-2693
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-721-6626
-----------------------------------------------------
Fax | 787-725-1287
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MYRIAM SAEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 787-721-6626
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 1158
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------