Laboratorio Clinico Fajardo, Inc.

Primary specialty

Clinical Medical LaboratoryTaxonomy code 291U00000X

License

1106 Issued in PR

Legal business name

LABORATORIO CLINICO FAJARDO, INC.

Practice address

40 Carr 194
Ste. 100 Fdo. Cinema BLDG
Fajardo, PR 00738-2940

Phone

(787) 863-5952

Fax

(787) 863-3116

NPI assigned

Apr 27, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Wanda Ivette Aviles, MT

Title

Owner-President of Corp-Lab. Superv

Phone

(787) 863-5952

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in PR

Enrollment records 1

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146096000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1671062400000",
    "number": "1740247253",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "40 CARR 194",
            "address_2": "SUITE 100",
            "city": "FAJARDO",
            "state": "PR",
            "postal_code": "007382940",
            "telephone_number": "787-863-5952",
            "fax_number": "787-863-3116"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "40 CARR 194",
            "address_2": "STE. 100 FDO. CINEMA BLDG",
            "city": "FAJARDO",
            "state": "PR",
            "postal_code": "007382940",
            "telephone_number": "787-863-5952",
            "fax_number": "787-863-3116"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "MONTESOL SHOOPING CENTER",
            "address_2": "LOCAL 106",
            "address_purpose": "LOCATION",
            "city": "FAJARDO",
            "state": "PR",
            "postal_code": "00738",
            "country_code": "US",
            "telephone_number": "787-648-9360",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "CALLE 13 PARCELA 52",
            "address_2": "BO FORTUNA II",
            "address_purpose": "LOCATION",
            "city": "LUQUILLO",
            "state": "PR",
            "postal_code": "00773",
            "country_code": "US",
            "telephone_number": "787-534-4329",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "LABORATORIO CLINICO FAJARDO, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-04-27",
        "last_updated": "2022-12-15",
        "certification_date": "2022-12-13",
        "status": "A",
        "authorized_official_last_name": "AVILES",
        "authorized_official_first_name": "WANDA",
        "authorized_official_middle_name": "IVETTE",
        "authorized_official_title_or_position": "OWNER-PRESIDENT OF CORP-LAB. SUPERV",
        "authorized_official_telephone_number": "787-863-5952",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "MT"
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "PR",
            "license": "1106",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Clinical Medical Laboratory in Fajardo, PR
• Providers in Fajardo, PR by specialty
• Clinical Medical Laboratory in Puerto Rico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.