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General NPI Number Information
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NPI Number | 1528678323
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Entity Type | Organization
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Legal Business Name | LABORATORIO EBENEZER LLC
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Dates
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Enumeration Date | 08/06/2020
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Last Update Date | 08/06/2020
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Provider Practice Location Address
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Address Line | BO MACANA CARR 132 KM 4.5
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City | GUAYANILLA
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State | PR
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Zip | 00656
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Country | US
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Telephone | 787-630-9149
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Fax |
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Provider Business Mailing Address
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Address Line | HC 1 BOX 6131
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City | GUAYANILLA
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State | PR
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Zip | 00656-9444
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Country | US
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Telephone | 787-630-9149
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. DAGMAR JOMARIE CORREA
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Credential | MS,MT
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Telephone | 787-630-9149
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number |
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License Number State |
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