Basic Information
| Provider Information | |||||||||
| NPI: | 1538445630 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | QUEST DIAGNOSTICS OF PUERTO RICO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 ADAMS AVE | ||||||||
| Address2: | 2ND FLOOR MRGOV | ||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194032429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4846767000 | ||||||||
| FaxNumber: | 4846765309 | ||||||||
| Practice Location | |||||||||
| Address1: | CALLE HIPODROMO 803 PDA 20 | ||||||||
| Address2: | |||||||||
| City: | SANTURCE | ||||||||
| State: | PR | ||||||||
| PostalCode: | 009092516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7874742900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2011 | ||||||||
| LastUpdateDate: | 08/19/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 04/25/2014 | ||||||||
| NPIReactivationDate: | 07/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | LAKE | ||||||||
| AuthorizedOfficialFirstName: | J PABLO | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP, REVENUE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4846767000 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | QUEST DIAGNOSTICS INCORPORATED | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.