Healthcare Provider Details

I. General information

NPI: 1679115208
Provider Name (Legal Business Name): ALICIA ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 10/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 W FLAMINGO RD STE 25AB
LAS VEGAS NV
89103-3705
US

IV. Provider business mailing address

2809 AUTUMN HAZE LN
LAS VEGAS NV
89117-0635
US

V. Phone/Fax

Practice location:
  • Phone: 702-871-9917
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: