Provider Demographics
NPI:1154603546
Name:WAXALI INC
Entity type:Organization
Organization Name:WAXALI INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:COLLAZO-ROSADO
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-869-1111
Mailing Address - Street 1:HC 72 BOX 3954
Mailing Address - Street 2:
Mailing Address - City:NARANJITO
Mailing Address - State:PR
Mailing Address - Zip Code:00719-8771
Mailing Address - Country:US
Mailing Address - Phone:787-869-1111
Mailing Address - Fax:787-869-2318
Practice Address - Street 1:RIO DEL PLATA MALL,URB JARDINES DE TOA ALTA,CALLE # 1
Practice Address - Street 2:SUITE # 8
Practice Address - City:TOA ALTA
Practice Address - State:PR
Practice Address - Zip Code:00953
Practice Address - Country:US
Practice Address - Phone:787-545-3200
Practice Address - Fax:787-545-3201
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAXALI INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-09-13
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1248291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1248OtherLICENCIA ESTATAL PUERTO RICO
PR11-025OtherCERTIFICADO DE NECESIDAD Y CONVENIENCIA
PR40D2027377OtherCLIA
PR0038245Medicare PIN