Healthcare Provider Details

I. General information

NPI: 1871328591
Provider Name (Legal Business Name): ROGELIO ROQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2024
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6762 LEXINGTON AVE
LOS ANGELES CA
90038-1217
US

IV. Provider business mailing address

6762 LEXINGTON AVE
LOS ANGELES CA
90038-1217
US

V. Phone/Fax

Practice location:
  • Phone: 323-380-7590
  • Fax:
Mailing address:
  • Phone: 323-380-7590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: