Healthcare Provider Details

I. General information

NPI: 1356076954
Provider Name (Legal Business Name): ROIDY VIQUILLON GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2022
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3G ROBERTA ST
KEY WEST FL
33040-5756
US

IV. Provider business mailing address

3G ROBERTA ST
KEY WEST FL
33040-5756
US

V. Phone/Fax

Practice location:
  • Phone: 305-879-8640
  • Fax:
Mailing address:
  • Phone: 305-879-8640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberL22000256793
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: