Provider Demographics
NPI:1437374154
Name:POLAK, LAURA (DC)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:POLAK
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 1:7145 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4319
Mailing Address - Country:US
Mailing Address - Phone:707-824-0340
Mailing Address - Fax:707-824-0340
Practice Address - Street 1:7145 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4319
Practice Address - Country:US
Practice Address - Phone:707-824-0340
Practice Address - Fax:707-824-0340
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC28151111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU948Medicare UPIN