MEDICARE: MAYAGUEZ ENDOCRINE & CLINICAL LAB

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	170	PR

General Provider Information

NPI Number	:	1114920956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAYAGUEZ ENDOCRINE & CLINICAL LAB

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	:	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

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

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	11/27/2023

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