MEDICARE: LABORATORIO CLINICO SANDON INC

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	362	PR

General Provider Information

NPI Number	:	1013910512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LABORATORIO CLINICO SANDON INC

Provider Business Mailing Address
First Line	:	PO BOX 335028
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00733-5028
Country	:	US
Telephone Number	:	787-844-4655
Fax Number	:	787-843-7868

Provider Business Practice Location Address
First Line	:	12 CALLE BERTOLY
Second Line	:
City	:	PONCE
State	:	PR
Zip	:	00730-3060
Country	:	US
Telephone Number	:	787-844-4655
Fax Number	:	787-843-7868

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. BEVERLYN D ACEVEDO
Credential	:	MT
Telephone Number	:	787-502-9700

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	11/05/2009

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