Provider Demographics
NPI:1609824119
Name:LABORATORIO CLINICO DE DIEGO CORP
Entity type:Organization
Organization Name:LABORATORIO CLINICO DE DIEGO CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FIDEL
Authorized Official - Middle Name:CLEMENTE
Authorized Official - Last Name:DE FRIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-891-6350
Mailing Address - Street 1:PO BOX 5183
Mailing Address - Street 2:
Mailing Address - City:AGUADILLA
Mailing Address - State:PR
Mailing Address - Zip Code:00605
Mailing Address - Country:US
Mailing Address - Phone:787-891-6350
Mailing Address - Fax:
Practice Address - Street 1:27TH AVE SEVERIANO CUEVAS
Practice Address - Street 2:
Practice Address - City:AGUADILLA
Practice Address - State:PR
Practice Address - Zip Code:00603
Practice Address - Country:US
Practice Address - Phone:787-891-6350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
6708291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
D26732Medicare UPIN
31285Medicare ID - Type Unspecified