Provider Demographics
NPI:1093718595
Name:ANGELA M ROQUE
Entity Type:Organization
Organization Name:ANGELA M ROQUE
Other - Org Name:USA DIABETIC SUPPLIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MATILDE
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-362-7227
Mailing Address - Street 1:320 KNOB HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-4646
Mailing Address - Country:US
Mailing Address - Phone:561-362-7227
Mailing Address - Fax:561-362-6959
Practice Address - Street 1:320 KNOB HILL BLVD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-4646
Practice Address - Country:US
Practice Address - Phone:561-362-7227
Practice Address - Fax:561-362-6959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2003-10159332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ773326Medicaid
TX1569725-02Medicaid
KY90006545Medicaid
AL009917475Medicaid
AZ773326Medicaid