MEDICARE: LABORATORIO CLINICO TIERRA SANTA 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	1021	PR

General Provider Information

NPI Number	:	1598741753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LABORATORIO CLINICO TIERRA SANTA INC

Provider Business Mailing Address
First Line	:	507 BO TIERRA SANTA # 149
Second Line	:
City	:	VILLALBA
State	:	PR
Zip	:	00766-2377
Country	:	US
Telephone Number	:	787-847-6948
Fax Number	:	787-847-6948

Provider Business Practice Location Address
First Line	:	507 CARR 149
Second Line	:	BO TIERRA SANTA
City	:	VILLALBA
State	:	PR
Zip	:	00766
Country	:	US
Telephone Number	:	787-847-6948
Fax Number	:	787-847-6948

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DOMINGO FIGUEROA ECHEUARRIA
Credential	:	LDO
Telephone Number	:	787-847-6948

Provider Enumeration Date	:	12/20/2005
Last Update Date	:	04/26/2016

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