Provider Demographics
NPI:1053349134
Name:CAMPO RICO CLINI-LAB, INC.
Entity type:Organization
Organization Name:CAMPO RICO CLINI-LAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IVONNE
Authorized Official - Middle Name:L
Authorized Official - Last Name:VELEZ TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:MT
Authorized Official - Phone:787-256-6417
Mailing Address - Street 1:PO BOX 20,000
Mailing Address - Street 2:PMB 468
Mailing Address - City:CANOVANAS
Mailing Address - State:PR
Mailing Address - Zip Code:00729
Mailing Address - Country:US
Mailing Address - Phone:787-256-6417
Mailing Address - Fax:787-256-6417
Practice Address - Street 1:CARR. #185, KM. 5.0
Practice Address - Street 2:BO. CAMPO RICO
Practice Address - City:CANOVANAS
Practice Address - State:PR
Practice Address - Zip Code:00729
Practice Address - Country:US
Practice Address - Phone:787-256-6417
Practice Address - Fax:787-256-6417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1077291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0031421Medicare ID - Type Unspecified