Provider Demographics
NPI:1902802671
Name:LABORATORIO CLINICO PENA POBRE CSP
Entity Type:Organization
Organization Name:LABORATORIO CLINICO PENA POBRE CSP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAMONA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSADO ROSADO
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-874-1698
Mailing Address - Street 1:BH12 CALLE 33 VILLA UNIVERSITARIA
Mailing Address - Street 2:
Mailing Address - City:HUMACAO
Mailing Address - State:PR
Mailing Address - Zip Code:00791-4363
Mailing Address - Country:US
Mailing Address - Phone:787-874-1698
Mailing Address - Fax:787-874-1698
Practice Address - Street 1:ROAD 31 KM 13.0
Practice Address - Street 2:BO PENA POBRE
Practice Address - City:NAGUABO
Practice Address - State:PR
Practice Address - Zip Code:00718
Practice Address - Country:US
Practice Address - Phone:787-874-1698
Practice Address - Fax:787-874-1698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR872291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR872OtherSTATE LICENSE NUMBER
PR0031101Medicare ID - Type Unspecified