Healthcare Provider Details

I. General information

NPI: 1386708766
Provider Name (Legal Business Name): MR. ROGER EARL LOCKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 PHELAN AVE #1
SAN JOSE CA
95112-6120
US

IV. Provider business mailing address

75 PHELAN AVE #1
SAN JOSE CA
95112-6120
US

V. Phone/Fax

Practice location:
  • Phone: 408-279-3955
  • Fax: 408-259-4350
Mailing address:
  • Phone: 408-279-3955
  • Fax: 408-259-4350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberSR GH 26792253
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: