Healthcare Provider Details

I. General information

NPI: 1780493353
Provider Name (Legal Business Name): IVIS DE LA CARIDAD ROQUE PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2025
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 NW 82ND AVE
DORAL FL
33126-1011
US

IV. Provider business mailing address

9402 NW 120TH ST APT 23
HIALEAH GARDENS FL
33018-4191
US

V. Phone/Fax

Practice location:
  • Phone: 786-420-5924
  • Fax:
Mailing address:
  • Phone: 786-602-3007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-400297
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: