Provider Demographics
NPI:1194991422
Name:LABORATORIO CLINICO TIERRAS NUEVAS INC
Entity type:Organization
Organization Name:LABORATORIO CLINICO TIERRAS NUEVAS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARICARMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MALDONADO ROMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-884-4676
Mailing Address - Street 1:PO BOX 2427
Mailing Address - Street 2:
Mailing Address - City:MANATI
Mailing Address - State:PR
Mailing Address - Zip Code:00674-2427
Mailing Address - Country:US
Mailing Address - Phone:787-884-4676
Mailing Address - Fax:787-884-4676
Practice Address - Street 1:CARR 685 KM 2 9
Practice Address - Street 2:BO TIERRAS NUEVAS SALIENTE
Practice Address - City:MANATI
Practice Address - State:PR
Practice Address - Zip Code:00674
Practice Address - Country:US
Practice Address - Phone:787-884-4676
Practice Address - Fax:787-884-4676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1149291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0031644Medicare Oscar/Certification