Provider Demographics
NPI:1164746871
Name:ROQUE, CHARLES (PT)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ROQUE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 E WASHINGTON BLVD
Mailing Address - Street 2:STE 18
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-3959
Mailing Address - Country:US
Mailing Address - Phone:323-980-9825
Mailing Address - Fax:323-980-9898
Practice Address - Street 1:5211 E WASHINGTON BLVD
Practice Address - Street 2:STE 18
Practice Address - City:COMMERCE
Practice Address - State:CA
Practice Address - Zip Code:90040-3959
Practice Address - Country:US
Practice Address - Phone:323-980-9825
Practice Address - Fax:323-980-9898
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT24193225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT24193OtherPHYSICAL THERAPY BOARD OF CALIFORNIA