=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790996791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLORIA M MERCADO JIMENEZ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 08/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | CARR. #2 KM 96.8 BO. COCOS
-----------------------------------------------------
City | QUEBRADILLAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-895-6216
-----------------------------------------------------
Fax | 787-895-6216
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | CARR. #2 KM 96.8 BO. COCOS
-----------------------------------------------------
City | QUEBRADILLAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-895-6216
-----------------------------------------------------
Fax | 787-895-6216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. GLORIA M MERCADO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 787-895-6216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 893
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------