=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821127150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LABORATORIO CLINICO MAYAGUEZ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2007
-----------------------------------------------------
Last Update Date | 07/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 142 CALLE MAYAGUEZ PEREZ MORRIS
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00917-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-274-0551
-----------------------------------------------------
Fax | 787-274-0551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 142 CALLE MAYAGUEZ PEREZ MORRIS
-----------------------------------------------------
City | SAN JUAN
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00917-5117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-274-0551
-----------------------------------------------------
Fax | 163-073-3367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ENEIDA A MARTINEZ
-----------------------------------------------------
Credential | MT
-----------------------------------------------------
Telephone | 787-274-0551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 930
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------