Provider Demographics
NPI:1043875867
Name:LA ROQUE, VLADIMIR
Entity Type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:
Last Name:LA 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 1:10520 NW 26TH ST STE C201
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2161
Mailing Address - Country:US
Mailing Address - Phone:305-364-5182
Mailing Address - Fax:305-456-6243
Practice Address - Street 1:10520 NW 26TH ST STE C201
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-2161
Practice Address - Country:US
Practice Address - Phone:305-364-5182
Practice Address - Fax:305-456-6243
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-07
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator