Healthcare Provider Details

I. General information

NPI: 1043155039
Provider Name (Legal Business Name): MR. SHAWN EDWARD ROQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4510 E PACIFIC COAST HWY STE 600
LONG BEACH CA
90804-6914
US

IV. Provider business mailing address

4510 E PACIFIC COAST HWY STE 600
LONG BEACH CA
90804-6914
US

V. Phone/Fax

Practice location:
  • Phone: 562-346-1100
  • Fax: 562-961-7604
Mailing address:
  • Phone: 562-346-1100
  • Fax: 562-961-7604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: