Healthcare Provider Details

I. General information

NPI: 1689776569
Provider Name (Legal Business Name): RICHMOND E ROESKE A PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 09/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41877 ENTERPRISE CIR N STE 110
TEMECULA CA
92590-5656
US

IV. Provider business mailing address

41877 ENTERPRISE CIR N STE 110
TEMECULA CA
92590-5656
US

V. Phone/Fax

Practice location:
  • Phone: 951-296-2244
  • Fax: 951-296-3602
Mailing address:
  • Phone: 951-296-2244
  • Fax: 951-296-3602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA64048
License Number StateCA

VIII. Authorized Official

Name: RICHMOND E ROESKE
Title or Position: PRES
Credential: MD
Phone: 951-296-2244