Provider Demographics
NPI:1710763289
Name:ROCHE, TANNER MCCLOUD (PT, DPT)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:MCCLOUD
Last Name:ROCHE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 MARINA DR APT 10
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-4240
Mailing Address - Country:US
Mailing Address - Phone:949-235-3951
Mailing Address - Fax:
Practice Address - Street 1:3257 CAMINO DE LOS COCHES STE 301
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-8974
Practice Address - Country:US
Practice Address - Phone:310-386-6788
Practice Address - Fax:760-652-5134
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304807225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist