Provider Demographics
NPI:1164628970
Name:POLANCO, JULIETA
Entity Type:Individual
Prefix:
First Name:JULIETA
Middle Name:
Last Name:POLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:846 WILLIAMSTON ST
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5245
Mailing Address - Country:US
Mailing Address - Phone:760-407-1220
Mailing Address - Fax:
Practice Address - Street 1:846 WILLIAMSTON ST
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5245
Practice Address - Country:US
Practice Address - Phone:760-407-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator