=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750606604
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LABORATORIO CLINICO CIBUCO INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2010
-----------------------------------------------------
Last Update Date | 08/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARRETERA 159 KILOMETRO 7.5
-----------------------------------------------------
City | COROZAL
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-381-2732
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 710 CALLE COCATIER LOS MONTES
-----------------------------------------------------
City | DORADO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00646-9464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-381-2732
-----------------------------------------------------
Fax | 787-875-3510
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. EVELYN SARRAGA
-----------------------------------------------------
Credential | LCDA
-----------------------------------------------------
Telephone | 787-381-2732
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------