Healthcare Provider Details

I. General information

NPI: 1346951183
Provider Name (Legal Business Name): DANIELLE ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 WILSHIRE BLVD
LOS ANGELES CA
90017-2431
US

IV. Provider business mailing address

13608 CAMBRIDGE PL
CHINO CA
91710-6603
US

V. Phone/Fax

Practice location:
  • Phone: 213-624-3556
  • Fax:
Mailing address:
  • Phone: 909-573-4895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number303323
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: