Provider Demographics
NPI:1306088158
Name:LABORATORIO CLINICO EXPRESO JVG
Entity type:Organization
Organization Name:LABORATORIO CLINICO EXPRESO JVG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TECNOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLAFANE
Authorized Official - Suffix:
Authorized Official - Credentials:LCDA
Authorized Official - Phone:787-983-7399
Mailing Address - Street 1:CARR 149 KM 9.8 INTERSECCION CAMPAMENTO
Mailing Address - Street 2:
Mailing Address - City:CIALES
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00703
Mailing Address - Country:UM
Mailing Address - Phone:787-983-7399
Mailing Address - Fax:
Practice Address - Street 1:CARR 149 KM 9.8
Practice Address - Street 2:
Practice Address - City:CIALES
Practice Address - State:PR
Practice Address - Zip Code:00638
Practice Address - Country:US
Practice Address - Phone:787-983-7399
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-25
Last Update Date:2009-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1042291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0031406Medicare PIN