Healthcare Provider Details

I. General information

NPI: 1750839080
Provider Name (Legal Business Name): SCOTT ROQUEMORE ATC, EMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2016
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25621 PURPLE SAGE LN
SAN JUAN CAPISTRANO CA
92675-4322
US

IV. Provider business mailing address

25621 PURPLE SAGE LN
SAN JUAN CAPISTRANO CA
92675-4322
US

V. Phone/Fax

Practice location:
  • Phone: 949-636-6872
  • Fax:
Mailing address:
  • Phone: 949-636-6872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2000011868
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: