Provider Demographics
NPI:1245601509
Name:POLEY, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:POLEY
Suffix:
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 1:8759 W CORNELL AVE
Mailing Address - Street 2:8
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80227-4879
Mailing Address - Country:US
Mailing Address - Phone:720-940-6335
Mailing Address - Fax:
Practice Address - Street 1:7007 E 88TH AVE
Practice Address - Street 2:L-50
Practice Address - City:HENDERSON
Practice Address - State:CO
Practice Address - Zip Code:80640-8214
Practice Address - Country:US
Practice Address - Phone:720-940-6335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician