Healthcare Provider Details

I. General information

NPI: 1477331296
Provider Name (Legal Business Name): JORGE MANUEL ROQUE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2023
Last Update Date: 09/21/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

URB SAN DEMETRIO AVE SAN DEMETRIO D-2
VEGA BAJA PR
00693
US

IV. Provider business mailing address

URB SAN DEMETRIO AVE SAN DEMETRIO D-2
VEGA BAJA PR
00693
US

V. Phone/Fax

Practice location:
  • Phone: 787-246-0901
  • Fax:
Mailing address:
  • Phone: 787-246-0901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number000760
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: