Provider Demographics
NPI:1063918639
Name:ROQUE, LUIS ALBERTO
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:ALBERTO
Last Name:ROQUE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-6603
Mailing Address - Country:US
Mailing Address - Phone:786-759-3274
Mailing Address - Fax:
Practice Address - Street 1:1790 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-6603
Practice Address - Country:US
Practice Address - Phone:786-759-3274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician