Provider Demographics
NPI:1891842159
Name:ILLIAD E HERNANDEZ LOPEZ
Entity type:Organization
Organization Name:ILLIAD E HERNANDEZ LOPEZ
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MT
Authorized Official - Prefix:
Authorized Official - First Name:ILLIAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-877-1895
Mailing Address - Street 1:PO BOX 357
Mailing Address - Street 2:
Mailing Address - City:MOCA
Mailing Address - State:PR
Mailing Address - Zip Code:00676-0357
Mailing Address - Country:US
Mailing Address - Phone:787-877-1895
Mailing Address - Fax:787-877-1895
Practice Address - Street 1:85 CALLE DON CHEMARY
Practice Address - Street 2:
Practice Address - City:MOCA
Practice Address - State:PR
Practice Address - Zip Code:00676-4120
Practice Address - Country:US
Practice Address - Phone:787-877-1895
Practice Address - Fax:787-877-1895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
291U00000X
PR610291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0030836Medicaid