MEDICARE: LABORATORIO CLINICO BACO STAT-LAB II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	291U00000X	Clinical Medical Laboratory	897	PR

General Provider Information

NPI Number	:	1013036375
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LABORATORIO CLINICO BACO STAT-LAB II

Provider Business Mailing Address
First Line	:	22 NORTH PERAL ST
Second Line	:
City	:	MAYAGUEZ
State	:	PR
Zip	:	00680-4821
Country	:	US
Telephone Number	:	787-832-7190
Fax Number	:	787-805-2045

Provider Business Practice Location Address
First Line	:	CARR 2, KM 149 HM 5, BO SABANETAS SUITE NUM 15
Second Line	:
City	:	MAYAGUEZ
State	:	PR
Zip	:	00680-4821
Country	:	US
Telephone Number	:	787-832-0033
Fax Number	:	787-805-2045

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. JORGE B BACO BROGNIEZ
Credential	:	B.S.M.T.(ASCP)GS
Telephone Number	:	787-429-2007

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	11/27/2023

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