Healthcare Provider Details

I. General information

NPI: 1508559204
Provider Name (Legal Business Name): JUANA C ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/30/2023
Certification Date: 05/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S SR 7 #174
ROYAL PALM BEACH FL
33411
US

IV. Provider business mailing address

1007 GLADES GLANE DRIVE
BELLE GLADE FL
33430
US

V. Phone/Fax

Practice location:
  • Phone: 561-568-9367
  • Fax:
Mailing address:
  • Phone: 561-914-6958
  • 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: