Provider Demographics
NPI:1194709592
Name:MARICARMEN SANTOS MIRANDA
Entity type:Organization
Organization Name:MARICARMEN SANTOS MIRANDA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR, OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARICARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOS MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-894-1145
Mailing Address - Street 1:CALLE TOMAS JORDAN 5
Mailing Address - Street 2:
Mailing Address - City:UTUADO
Mailing Address - State:PR
Mailing Address - Zip Code:00641
Mailing Address - Country:US
Mailing Address - Phone:787-894-1145
Mailing Address - Fax:787-894-1145
Practice Address - Street 1:CALLE TOMAS JORDAN 5
Practice Address - Street 2:
Practice Address - City:UTUADO
Practice Address - State:PR
Practice Address - Zip Code:00641
Practice Address - Country:US
Practice Address - Phone:787-894-1145
Practice Address - Fax:787-894-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR573291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR31113OtherSSS
PR0030850Medicare PIN