Provider Demographics
NPI:1275516668
Name:LABORATORIO CLINICO JARDINES DE YABUCOA
Entity type:Organization
Organization Name:LABORATORIO CLINICO JARDINES DE YABUCOA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:A
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-893-7702
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:YABUCOA
Mailing Address - State:PR
Mailing Address - Zip Code:00767
Mailing Address - Country:US
Mailing Address - Phone:787-893-7702
Mailing Address - Fax:787-893-7702
Practice Address - Street 1:URBANIZACION MENDEZ #95 CALLE A
Practice Address - Street 2:
Practice Address - City:YABUCOA
Practice Address - State:PR
Practice Address - Zip Code:00767
Practice Address - Country:US
Practice Address - Phone:787-893-7702
Practice Address - Fax:787-893-7702
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LABORATORIO CLINICO Y BACTERIOLOGICO GLADY AN INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-21
Last Update Date:2017-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR817291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
40D0861099OtherCLIA
PR0030804Medicare ID - Type Unspecified