=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770514150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LABORATORIO CLINICO HNOS MIKASOBE,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 05/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 68 CALLE BETANCES
-----------------------------------------------------
City | CANOVANAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00729-3243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-876-3697
-----------------------------------------------------
Fax | 787-256-5538
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10,0000 PMB 157
-----------------------------------------------------
City | CANOVANAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00729-3243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-876-3697
-----------------------------------------------------
Fax | 787-256-5538
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ILEANA DURAN
-----------------------------------------------------
Credential | MT
-----------------------------------------------------
Telephone | 787-876-3697
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 342
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------