Provider Demographics
NPI:1700408606
Name:ROACH, CHERISE (OWNER)
Entity Type:Individual
Prefix:
First Name:CHERISE
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 CROWN ISLE CIR
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-2914
Mailing Address - Country:US
Mailing Address - Phone:407-252-2741
Mailing Address - Fax:
Practice Address - Street 1:1316 CROWN ISLE CIR
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-2914
Practice Address - Country:US
Practice Address - Phone:407-252-2741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLR200113627100172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL844477411Medicaid