Healthcare Provider Details

I. General information

NPI: 1063918639
Provider Name (Legal Business Name): MR. LUIS ALBERTO ROQUE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 SW 3RD ST
HOMESTEAD FL
33030-6603
US

IV. Provider business mailing address

1790 SW 3RD ST
HOMESTEAD FL
33030-6603
US

V. Phone/Fax

Practice location:
  • Phone: 786-759-3274
  • Fax:
Mailing address:
  • Phone: 786-759-3274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: