Provider Demographics
NPI:1316335714
Name:ROQUE, GENESIS
Entity type:Individual
Prefix:
First Name:GENESIS
Middle Name:
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 1:5371 W 4100 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-4727
Mailing Address - Country:US
Mailing Address - Phone:801-688-0396
Mailing Address - Fax:
Practice Address - Street 1:5371 W 4100 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-4727
Practice Address - Country:US
Practice Address - Phone:801-688-0396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171R00000XOther Service ProvidersInterpreter