Healthcare Provider Details

I. General information

NPI: 1023368032
Provider Name (Legal Business Name): LEWIS ALLEN ROQUE RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2012
Last Update Date: 09/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 BENTON ST
LOMA LINDA CA
92357-1000
US

IV. Provider business mailing address

40444 CHIP CT
PALMDALE CA
93551-2654
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone: 661-524-3735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number30251
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: