Healthcare Provider Details

I. General information

NPI: 1710713573
Provider Name (Legal Business Name): MANUEL ALEJANDRO ROQUE LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13315 SW 253RD TER
HOMESTEAD FL
33032-5677
US

IV. Provider business mailing address

13315 SW 253RD TER
HOMESTEAD FL
33032-5677
US

V. Phone/Fax

Practice location:
  • Phone: 561-663-9140
  • Fax:
Mailing address:
  • Phone: 561-663-9140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number24372431
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: