MEDICARE: MISS ZAHIRA V VEGA BONILLA MT

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	406	PR

General Provider Information

NPI Number	:	1588753685
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ZAHIRA V VEGA BONILLA MT

Provider Business Mailing Address
First Line	:	PO BOX 1048
Second Line	:
City	:	GUANICA
State	:	PR
Zip	:	00653-1048
Country	:	US
Telephone Number	:	787-821-2350
Fax Number	:	787-821-2350

Provider Business Practice Location Address
First Line	:	CALLE SAN MIGUEL NO 42
Second Line	:
City	:	GUANICA
State	:	PR
Zip	:	00653-1048
Country	:	US
Telephone Number	:	787-821-2350
Fax Number	:	787-821-2350

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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