Healthcare Provider Details

I. General information

NPI: 1407497076
Provider Name (Legal Business Name): GUADALUPE ROCHA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 BROCKTON AVE STE 203
RIVERSIDE CA
92506-3818
US

IV. Provider business mailing address

14726 RAMONA AVE STE 203
CHINO CA
91710-5730
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-4353
  • Fax:
Mailing address:
  • Phone: 626-305-9100
  • Fax: 626-305-0152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number34684TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: