Healthcare Provider Details

I. General information

NPI: 1417605288
Provider Name (Legal Business Name): JEFFREY ROQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1359 N GRAND AVE
COVINA CA
91724-1016
US

IV. Provider business mailing address

4095 IRISH MOSS LN
SAN BERNARDINO CA
92407-0620
US

V. Phone/Fax

Practice location:
  • Phone: 626-430-2900
  • Fax:
Mailing address:
  • Phone: 562-308-0515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95043465
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: