Provider Demographics
NPI:1588705867
Name:EDILFREDO HERNANDEZ
Entity type:Organization
Organization Name:EDILFREDO HERNANDEZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDILFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-766-1464
Mailing Address - Street 1:576 CALLE CESAR GONZALEZ
Mailing Address - Street 2:OFIC. 101C
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00918-3756
Mailing Address - Country:US
Mailing Address - Phone:787-766-1464
Mailing Address - Fax:787-773-0766
Practice Address - Street 1:576 CALLE CESAR GONZALEZ
Practice Address - Street 2:OFIC. 101C
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00918-3756
Practice Address - Country:US
Practice Address - Phone:787-766-1464
Practice Address - Fax:787-773-0766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR711291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR31414Medicare PIN