Provider Demographics
NPI:1992901318
Name:CLINILAB
Entity type:Organization
Organization Name:CLINILAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:CELESTE
Authorized Official - Last Name:CHICO
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-892-0520
Mailing Address - Street 1:P.O. BOX 268
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-0268
Mailing Address - Country:US
Mailing Address - Phone:787-892-0520
Mailing Address - Fax:
Practice Address - Street 1:AVE LOS ATLETICOS DE SAN GERMAN #222
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683
Practice Address - Country:US
Practice Address - Phone:787-892-0520
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR915291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR=========OtherSSN