Basic Information
Provider Information | |||||||||
NPI: | 1598379190 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | QUEST DIAGNOSTICS OF PUERTO RICO, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 107 AVE ORTEGON | ||||||||
Address2: | STE 105 | ||||||||
City: | GUAYNABO | ||||||||
State: | PR | ||||||||
PostalCode: | 009662516 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7874742900 | ||||||||
FaxNumber: | 7877655663 | ||||||||
Practice Location | |||||||||
Address1: | 2929 AVE EMILIO FAGOT | ||||||||
Address2: |   | ||||||||
City: | PONCE | ||||||||
State: | PR | ||||||||
PostalCode: | 007163613 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7874742900 | ||||||||
FaxNumber: | 7877655663 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/02/2020 | ||||||||
LastUpdateDate: | 09/02/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ESPINOSA | ||||||||
AuthorizedOfficialFirstName: | OMAYRA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7874742900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | QUEST DIAGNOSTICS OF PUERTO RICO, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/02/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X |   |   | Y |   | Laboratories | Clinical Medical Laboratory |   |
No ID Information.