Provider Demographics
NPI:1275537177
Name:POLSEMEN, MARY KAY (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY KAY
Middle Name:
Last Name:POLSEMEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3150 CROW CANYON PL
Mailing Address - Street 2:STE 120
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1778
Mailing Address - Country:US
Mailing Address - Phone:925-830-8635
Mailing Address - Fax:925-830-8652
Practice Address - Street 1:3150 CROW CANYON PL
Practice Address - Street 2:STE 120
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1778
Practice Address - Country:US
Practice Address - Phone:925-830-8635
Practice Address - Fax:925-830-8652
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23832111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACY272AOtherMEDICARE PTAN