Provider Demographics
NPI:1093489254
Name:POLANCO, JOSE LUIS III
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:POLANCO
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10819 ELLIOTT AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91733-2337
Mailing Address - Country:US
Mailing Address - Phone:626-274-9404
Mailing Address - Fax:
Practice Address - Street 1:10819 ELLIOTT AVE APT 2
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91733-2337
Practice Address - Country:US
Practice Address - Phone:626-274-9404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty