MEDICARE: LABORATORIO VASCULAR CLINICO 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	2085U0001X	Diagnostic Ultrasound Physician		PR

General Provider Information

NPI Number	:	1578560314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LABORATORIO VASCULAR CLINICO INC

Provider Business Mailing Address
First Line	:	PO BOX 194478
Second Line	:
City	:	SAN JUAN
State	:	PR
Zip	:	00919-4814
Country	:	US
Telephone Number	:	787-758-7500
Fax Number	:	787-758-0975

Provider Business Practice Location Address
First Line	:	716 PONCE DE LEON AVE.
Second Line	:
City	:	HATO REY
State	:	PR
Zip	:	00918-4510
Country	:	US
Telephone Number	:	787-758-7500
Fax Number	:	787-758-0975

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	GUILLERMO ACARON SOUFFRONT
Credential	:	MD
Telephone Number	:	787-758-7500

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/21/2022

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