MEDICARE: LABORATORIO CLINICO EL SHADDAI,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	1148	PR

General Provider Information

NPI Number	:	1164696134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LABORATORIO CLINICO EL SHADDAI,INC.

Provider Business Mailing Address
First Line	:	PO BOX 5005
Second Line	:	PMB 23
City	:	SAN LORENZO
State	:	PR
Zip	:	00754-5005
Country	:	US
Telephone Number	:	787-249-5350
Fax Number	:	787-736-8838

Provider Business Practice Location Address
First Line	:	CARR 183 # KM7.7
Second Line	:	BO. HATO
City	:	SAN LORENZO
State	:	PR
Zip	:	00754-4530
Country	:	US
Telephone Number	:	787-249-5350
Fax Number	:	787-736-8838

Authorized Official
Title or Position	:	MEDICAL TECHNOLOGIST
Name	:	CARMEN S. ORTIZ
Credential	:	M.T.
Telephone Number	:	787-249-5350

Provider Enumeration Date	:	04/21/2008
Last Update Date	:	04/21/2008

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