Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251G0304X | Physical Therapist - Geriatrics | PT 11025 | FL |
NPI | 1063516664 |
---|---|
Provider Name | Mr. Ronan Leva Roque |
First Address | Ocoee, FL 34761-3351 |
Second Address | Ocoee, FL 34761-3351 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/09/2006 |
Last Update Date | 08/07/2007 |