Provider Demographics
NPI:1780896571
Name:DANIEL R. ROQUE PT, P.C.
Entity type:Organization
Organization Name:DANIEL R. ROQUE PT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:P T
Authorized Official - Phone:219-670-5388
Mailing Address - Street 1:9209 MARIGOLD LANE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-3016
Mailing Address - Country:US
Mailing Address - Phone:219-670-5388
Mailing Address - Fax:
Practice Address - Street 1:9209 MARIGOLD LANE
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-3016
Practice Address - Country:US
Practice Address - Phone:219-670-5388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200833270AMedicaid
IN200833280Medicaid