Provider Demographics
NPI:1154782175
Name:MI LABORATORIO CLINICO COOP
Entity type:Organization
Organization Name:MI LABORATORIO CLINICO COOP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENTE
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-608-4600
Mailing Address - Street 1:CALLE COLON # 118
Mailing Address - Street 2:
Mailing Address - City:AGUADA
Mailing Address - State:PR
Mailing Address - Zip Code:00602-3166
Mailing Address - Country:US
Mailing Address - Phone:787-868-3339
Mailing Address - Fax:787-868-3339
Practice Address - Street 1:CARRETERA 115 KM 0.1
Practice Address - Street 2:BARRIO ASOMANTE
Practice Address - City:AGUADA
Practice Address - State:PR
Practice Address - Zip Code:00602-3166
Practice Address - Country:US
Practice Address - Phone:787-868-3339
Practice Address - Fax:787-868-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1169291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1169OtherLICENCIA DEPARTAMENTO DE SALUD
PR14-077OtherCNC