MEDICARE: ILLIAD E HERNANDEZ LOPEZ

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
2	291U00000X	Clinical Medical Laboratory	610	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891842159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLIAD E HERNANDEZ LOPEZ

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	:	787-877-1895

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	:	787-877-1895

Authorized Official
Title or Position	:	MT
Name	:	ILLIAD E HERNANDEZ
Credential	:
Telephone Number	:	787-877-1895

Provider Enumeration Date	:	01/05/2007
Last Update Date	:	09/23/2020

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