Basic Information
Provider Information | |||||||||
NPI: | 1679040273 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROCHE | ||||||||
FirstName: | RAYMA | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2076 | ||||||||
Address2: |   | ||||||||
City: | MANATI | ||||||||
State: | PR | ||||||||
PostalCode: | 006742076 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7873965356 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | EDIFICIO COMERCIAL LOCAL 1 | ||||||||
Address2: | 66 URB CATALANA | ||||||||
City: | BARCELONETA | ||||||||
State: | PR | ||||||||
PostalCode: | 00617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7879153000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2018 | ||||||||
LastUpdateDate: | 11/01/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 2144-1 | PR | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 6600836 | 01 | PR | DRIVERS LICENSE | OTHER |