Basic Information
| Provider Information | |||||||||
| NPI: | 1962750778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROQUE | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | MANUEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 664 CROOKED CREEK DRIVE | ||||||||
| Address2: | |||||||||
| City: | OCOEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079706097 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 LEXINGTON GREEN LANE | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076880070 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2012 | ||||||||
| LastUpdateDate: | 08/28/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 23530 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.