Provider Demographics
NPI:1124684543
Name:LABORATORIO CLINICO Y DE REFERENCIA PUERTO DEL REY, LLC
Entity type:Organization
Organization Name:LABORATORIO CLINICO Y DE REFERENCIA PUERTO DEL REY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:IVETTE
Authorized Official - Last Name:AVILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-534-7181
Mailing Address - Street 1:PO BOX 1635
Mailing Address - Street 2:
Mailing Address - City:LUQUILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00773-1635
Mailing Address - Country:US
Mailing Address - Phone:787-534-7181
Mailing Address - Fax:
Practice Address - Street 1:URB FAJARDO GARDENS
Practice Address - Street 2:696 CALLE CIPRES
Practice Address - City:FAJARDO
Practice Address - State:PR
Practice Address - Zip Code:00738
Practice Address - Country:US
Practice Address - Phone:787-534-7181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-10
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory