=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962621474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LABORATORIO CLINICO SONIA SEPULVEDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | STREET PEDRO VELAZQUEZ DIAZ 628 B1
-----------------------------------------------------
City | PENUELAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-836-2178
-----------------------------------------------------
Fax | 787-836-2255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 490
-----------------------------------------------------
City | PENUELAS
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00624-0490
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 787-836-2178
-----------------------------------------------------
Fax | 787-836-2255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. SONIA L SEPULVEDA
-----------------------------------------------------
Credential | MT LIC 975
-----------------------------------------------------
Telephone | 787-836-2178
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 347
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------