Provider Demographics
NPI:1063636546
Name:LABORATORIO CLINICO Y DE REFERENCIA DE FAJARDO, INC.
Entity type:Organization
Organization Name:LABORATORIO CLINICO Y DE REFERENCIA DE FAJARDO, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SEVERINO
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-741-8790
Mailing Address - Street 1:108 CALLE MUNOZ RIVERA
Mailing Address - Street 2:
Mailing Address - City:VIEQUES
Mailing Address - State:PR
Mailing Address - Zip Code:00765-3042
Mailing Address - Country:US
Mailing Address - Phone:787-741-8790
Mailing Address - Fax:787-741-2833
Practice Address - Street 1:108 CALLE MUNOZ RIVERA
Practice Address - Street 2:
Practice Address - City:VIEQUES
Practice Address - State:PR
Practice Address - Zip Code:00765-3042
Practice Address - Country:US
Practice Address - Phone:787-741-8790
Practice Address - Fax:787-741-2833
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LABORATORIO CLINICO Y DE REFERENCIA DE FAJARDO, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-13
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR742291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR38123Medicare ID - Type Unspecified