Healthcare Provider Details

I. General information

NPI: 1346015286
Provider Name (Legal Business Name): JOHN VINCENT GARO ROQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HILLMONT AVE
VENTURA CA
93003-1647
US

IV. Provider business mailing address

200 HILLMONT AVE
VENTURA CA
93003-1647
US

V. Phone/Fax

Practice location:
  • Phone: 805-652-6729
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95314970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: