Provider Demographics
NPI:1285868778
Name:ROQUE, MIRIAM
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:ROQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1869 RIVER RANCH DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-1469
Mailing Address - Country:US
Mailing Address - Phone:805-714-0923
Mailing Address - Fax:
Practice Address - Street 1:120 W CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-5913
Practice Address - Country:US
Practice Address - Phone:805-740-4555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-12
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator