Healthcare Provider Details

I. General information

NPI: 1962750778
Provider Name (Legal Business Name): VICTOR MANUEL ROQUE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 08/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 LEXINGTON GREEN LANE
SANFORD FL
32771
US

IV. Provider business mailing address

664 CROOKED CREEK DRIVE
OCOEE FL
34761
US

V. Phone/Fax

Practice location:
  • Phone: 407-688-0070
  • Fax:
Mailing address:
  • Phone: 407-970-6097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number23530
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: