Provider Demographics
NPI:1073748521
Name:GARCIA, LEA ROQUE (MT)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:ROQUE
Last Name:GARCIA
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 CAMELLIA TRCE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-3560
Mailing Address - Country:US
Mailing Address - Phone:865-684-0224
Mailing Address - Fax:865-981-2881
Practice Address - Street 1:318 CAMELLIA TRCE
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-3560
Practice Address - Country:US
Practice Address - Phone:865-684-0224
Practice Address - Fax:865-981-2881
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000005743171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor