Healthcare Provider Details

I. General information

NPI: 1851216584
Provider Name (Legal Business Name): ROQUE HERNANDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

879 W 190TH ST
GARDENA CA
90248-4220
US

IV. Provider business mailing address

11102 AVALON BLVD
LOS ANGELES CA
90061-3022
US

V. Phone/Fax

Practice location:
  • Phone: 310-819-4523
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number1-21-53574
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: