Provider Demographics
NPI:1982835542
Name:DE ROQUE, RICHARD EARL (PT)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:EARL
Last Name:DE 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 1:1840 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-7392
Mailing Address - Country:US
Mailing Address - Phone:501-472-1271
Mailing Address - Fax:501-513-9143
Practice Address - Street 1:74 CLEBURNE PARK RD
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-9106
Practice Address - Country:US
Practice Address - Phone:501-206-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2010-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPT1308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR125613721Medicaid