Healthcare Provider Details

I. General information

NPI: 1780284372
Provider Name (Legal Business Name): DRE'SHON J ROLLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2020
Last Update Date: 10/31/2020
Certification Date: 10/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28601 LOS ALISOS BLVD APT 1054
MISSION VIEJO CA
92692-7909
US

IV. Provider business mailing address

28601 LOS ALISOS BLVD APT 1054
MISSION VIEJO CA
92692-7909
US

V. Phone/Fax

Practice location:
  • Phone: 602-350-9515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: