Provider Demographics
NPI:1033140348
Name:ROQUEMORE, MICHAEL W (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:W
Last Name:ROQUEMORE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23133 HAWTHORNE BLVD
Mailing Address - Street 2:STE.108
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3729
Mailing Address - Country:US
Mailing Address - Phone:310-802-6661
Mailing Address - Fax:310-802-6668
Practice Address - Street 1:23133 HAWTHORNE BLVD
Practice Address - Street 2:STE.108
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3729
Practice Address - Country:US
Practice Address - Phone:310-802-6661
Practice Address - Fax:310-802-6668
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15369111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC15369Medicare ID - Type Unspecified
CA1033140348Medicare UPIN