Healthcare Provider Details

I. General information

NPI: 1013854694
Provider Name (Legal Business Name): JULIUS E. ROQUE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5156 ST ALBERT DR
FONTANA CA
92336-0635
US

IV. Provider business mailing address

5156 ST ALBERT DR
FONTANA CA
92336-0635
US

V. Phone/Fax

Practice location:
  • Phone: 310-484-6920
  • Fax:
Mailing address:
  • Phone: 310-484-6920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039390
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: