Provider Demographics
NPI:1053863316
Name:POLK, ZACHARY (LPT)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:POLK
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 FRANKLIN AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-6922
Mailing Address - Country:US
Mailing Address - Phone:254-754-0375
Mailing Address - Fax:254-754-2667
Practice Address - Street 1:5100 FRANKLIN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-6922
Practice Address - Country:US
Practice Address - Phone:254-754-0375
Practice Address - Fax:254-754-2667
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1248256225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist