Provider Demographics
NPI:1073640587
Name:POLANCO, MARIO (BS, DEGREE)
Entity Type:Individual
Prefix:MR
First Name:MARIO
Middle Name:
Last Name:POLANCO
Suffix:
Gender:M
Credentials:BS, DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 45195
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-0191
Mailing Address - Country:US
Mailing Address - Phone:323-887-7458
Mailing Address - Fax:323-887-8288
Practice Address - Street 1:5301 WHITTIER BLVD
Practice Address - Street 2:ATRIUM SUITE
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-4038
Practice Address - Country:US
Practice Address - Phone:323-887-7458
Practice Address - Fax:323-887-8288
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 11680174400000X
CA11680225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20-5607292OtherTAX ID#