Healthcare Provider Details

I. General information

NPI: 1619708617
Provider Name (Legal Business Name): ALICIA ROQUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2024
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 W RIVER RD N
ELYRIA OH
44035-2791
US

IV. Provider business mailing address

144 DAVID DR APT 8
ELYRIA OH
44035-2860
US

V. Phone/Fax

Practice location:
  • Phone: 440-324-5555
  • Fax:
Mailing address:
  • Phone: 440-830-0402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: