Healthcare Provider Details

I. General information

NPI: 1992338552
Provider Name (Legal Business Name): RALPH KEVIN ROQUE LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 02/21/2020
Certification Date: 02/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 W MANCHESTER BLVD, INGLEWOOD, CA 90301 104
INGLEWOOD CA
90301
US

IV. Provider business mailing address

7246 REMMET AVE
CANOGA PARK CA
91303-1531
US

V. Phone/Fax

Practice location:
  • Phone: 310-412-0879
  • Fax:
Mailing address:
  • Phone: 818-206-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number279433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: