Provider Demographics
NPI:1245405059
Name:ROCCO, TASHA NICHOLE
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:NICHOLE
Last Name:ROCCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TASHA
Other - Middle Name:
Other - Last Name:GOMEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1908 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-3436
Mailing Address - Country:US
Mailing Address - Phone:909-763-5500
Mailing Address - Fax:
Practice Address - Street 1:1053 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3521
Practice Address - Country:US
Practice Address - Phone:909-763-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7006Medicaid