Healthcare Provider Details

I. General information

NPI: 1164902599
Provider Name (Legal Business Name): VICTOR ROQUE-DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2330 PASEO DEL PRADO STE C307
LAS VEGAS NV
89102-0076
US

IV. Provider business mailing address

6492 LOMBARD DR
LAS VEGAS NV
89108-2700
US

V. Phone/Fax

Practice location:
  • Phone: 725-600-7953
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: