Provider Demographics
NPI:1124164140
Name:LABORATORIO CLINICO COVADONGA,INC
Entity type:Organization
Organization Name:LABORATORIO CLINICO COVADONGA,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTIAGO
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-251-0138
Mailing Address - Street 1:AA4 AVE DON PELAYO
Mailing Address - Street 2:HACIENDAS DEL NORTE
Mailing Address - City:TOA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00949-5388
Mailing Address - Country:US
Mailing Address - Phone:787-251-0138
Mailing Address - Fax:787-251-0130
Practice Address - Street 1:AA4 AVE DON PELAYO
Practice Address - Street 2:HACIENDAS DEL NORTE
Practice Address - City:TOA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00949-5388
Practice Address - Country:US
Practice Address - Phone:787-251-0138
Practice Address - Fax:787-251-0130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2007-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR00758291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR38346Medicare PIN