Provider Demographics
NPI:1992338552
Name:ROQUE, RALPH KEVIN (LVN)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:KEVIN
Last Name:ROQUE
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7246 REMMET AVE
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-1531
Mailing Address - Country:US
Mailing Address - Phone:818-206-0360
Mailing Address - Fax:
Practice Address - Street 1:614 W MANCHESTER BLVD, INGLEWOOD, CA 90301
Practice Address - Street 2:104
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301
Practice Address - Country:US
Practice Address - Phone:310-412-0879
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA279433164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse