Healthcare Provider Details

I. General information

NPI: 1386270155
Provider Name (Legal Business Name): ENRICO MASANGKAY ROQUE JR. OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 PANTHEON LN
SHREVEPORT LA
71115-4506
US

IV. Provider business mailing address

103 PANTHEON LN
SHREVEPORT LA
71115-4506
US

V. Phone/Fax

Practice location:
  • Phone: 318-393-1057
  • Fax:
Mailing address:
  • Phone: 318-393-1057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTT.200779
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: