Healthcare Provider Details

I. General information

NPI: 1669923959
Provider Name (Legal Business Name): ISIDRO ROQUE LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 10/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2460 W 26TH AVE STE 217
DENVER CO
80211-5308
US

IV. Provider business mailing address

5620 E 68TH AVE
COMMERCE CITY CO
80022-2524
US

V. Phone/Fax

Practice location:
  • Phone: 303-322-7108
  • Fax:
Mailing address:
  • Phone: 720-404-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number333121
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: