=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639594310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDLAB,CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2014
-----------------------------------------------------
Last Update Date | 03/04/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PR 109 KM 26.4 INT 497 BO CULEBRINA
-----------------------------------------------------
City | SAN SEBASTIAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00685
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-896-7298
-----------------------------------------------------
Fax | 787-896-7298
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 725
-----------------------------------------------------
City | SAN SEBASTIAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00685-0725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-896-7298
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JOHANNY RIVERA SERRANO
-----------------------------------------------------
Credential | MT LIC#6967 PR
-----------------------------------------------------
Telephone | 787-568-8833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 1307
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------