Healthcare Provider Details

I. General information

NPI: 1154299238
Provider Name (Legal Business Name): MICHEL ENRIQUE ROQUE RIOS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 NW 4TH PL
CAPE CORAL FL
33993-8761
US

IV. Provider business mailing address

2615 NW 4TH PL
CAPE CORAL FL
33993-8761
US

V. Phone/Fax

Practice location:
  • Phone: 954-305-4301
  • Fax:
Mailing address:
  • Phone: 954-305-4301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-484284
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: