=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952646127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DV LAB GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2012
-----------------------------------------------------
Last Update Date | 11/29/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | SAN LUIS AVE 933 129 ROAD MARGINAL
-----------------------------------------------------
City | ARECIBO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-680-7260
-----------------------------------------------------
Fax | 787-680-7260
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 142292
-----------------------------------------------------
City | ARECIBO
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00614-2292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-879-0749
-----------------------------------------------------
Fax | 787-816-4307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINSITRATOR
-----------------------------------------------------
Name | MRS. MAITE ROLON
-----------------------------------------------------
Credential | M.T.
-----------------------------------------------------
Telephone | 787-879-0749
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 1250
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------