MEDICARE: LABORATORIO CLINICO DY-MATOS, 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	431	PR

General Provider Information

NPI Number	:	1255367488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LABORATORIO CLINICO DY-MATOS, INC.

Provider Business Mailing Address
First Line	:	RR 7 BOX 17157
Second Line	:
City	:	TOA ALTA
State	:	PR
Zip	:	00953-8845
Country	:	US
Telephone Number	:	787-786-4589
Fax Number	:	787-798-0860

Provider Business Practice Location Address
First Line	:	C-25 MARGINAL
Second Line	:	EXTENSION FOREST HILLS
City	:	BAYAMON
State	:	PR
Zip	:	00959-0000
Country	:	US
Telephone Number	:	787-786-4589
Fax Number	:	787-798-0860

Authorized Official
Title or Position	:	PRESIDENT/DIRECTOR
Name	:	WENDY MATOS
Credential	:	LCDA.
Telephone Number	:	787-786-4589

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	07/09/2014

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