Provider Demographics
NPI:1174798052
Name:ORTIZ, CARMEN S (LCDA)
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:S
Last Name:ORTIZ
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5005 PMB 23
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:PR
Mailing Address - Zip Code:00754-5005
Mailing Address - Country:US
Mailing Address - Phone:787-249-5350
Mailing Address - Fax:787-736-8838
Practice Address - Street 1:CARR 183 # KM7.7
Practice Address - Street 2:BO. HATO
Practice Address - City:SAN LORENZO
Practice Address - State:PR
Practice Address - Zip Code:00754-4530
Practice Address - Country:US
Practice Address - Phone:787-249-5350
Practice Address - Fax:787-736-8838
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6387291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory