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General NPI Number Information
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NPI Number | 1982835542
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Entity Type | Individual
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Provider Name | RICHARD EARL DE ROQUE PT
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Gender | Male
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Dates
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Enumeration Date | 07/30/2009
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Last Update Date | 02/06/2010
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Provider Practice Location Address
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Address Line | 74 CLEBURNE PARK RD
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City | HEBER SPRINGS
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State | AR
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Zip | 72543-9106
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Country | US
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Telephone | 501-206-0920
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Fax |
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Provider Business Mailing Address
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Address Line | 1840 COLUMBIA DR
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City | CONWAY
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State | AR
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Zip | 72034-7392
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Country | US
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Telephone | 501-472-1271
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Fax | 501-513-9143
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | PT1308
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License Number State | AR
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