MEDICARE: LAB CLINICO HERNANDEZ 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	610	PR

General Provider Information

NPI Number	:	1336580638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAB CLINICO HERNANDEZ INC.

Provider Business Mailing Address
First Line	:	PO BOX 357
Second Line	:
City	:	MOCA
State	:	PR
Zip	:	00676-0357
Country	:	US
Telephone Number	:	787-877-1895
Fax Number	:	787-551-7020

Provider Business Practice Location Address
First Line	:	85 CALLE DON CHEMARY
Second Line	:
City	:	MOCA
State	:	PR
Zip	:	00676-4120
Country	:	US
Telephone Number	:	787-877-1895
Fax Number	:	787-551-7020

Authorized Official
Title or Position	:	LAB DIRECTOR
Name	:	MRS. ILLIAD E HERNANDEZ
Credential	:	M.T.
Telephone Number	:	787-877-1895

Provider Enumeration Date	:	07/15/2013
Last Update Date	:	07/15/2013

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