Healthcare Provider Details

I. General information

NPI: 1841749207
Provider Name (Legal Business Name): AVON ROQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11618 SOUTH ST UNIT 201
ARTESIA CA
90701-6618
US

IV. Provider business mailing address

11618 SOUTH ST UNIT 201
ARTESIA CA
90701-6618
US

V. Phone/Fax

Practice location:
  • Phone: 562-865-3355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA48266
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: