Provider Demographics
NPI:1902935406
Name:FERNANDO HERNANDEZ
Entity Type:Organization
Organization Name:FERNANDO HERNANDEZ
Other - Org Name:121 CENTURY MEDICAL LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1877-307-6654
Mailing Address - Street 1:713 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4412
Mailing Address - Country:US
Mailing Address - Phone:187-730-7665
Mailing Address - Fax:
Practice Address - Street 1:713 W 27TH ST
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4412
Practice Address - Country:US
Practice Address - Phone:187-730-7665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory