Healthcare Provider Details

I. General information

NPI: 1447779137
Provider Name (Legal Business Name): DEZARAY ROEBUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 ARLINGTON AVE STE 200
LOS ANGELES CA
90018-1353
US

IV. Provider business mailing address

2116 ARLINGTON AVE STE 200
LOS ANGELES CA
90018-1353
US

V. Phone/Fax

Practice location:
  • Phone: 323-737-3900
  • Fax:
Mailing address:
  • Phone: 323-737-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number734220
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: