Provider Demographics
NPI:1497449391
Name:POLANCO, SHIRLEY
Entity Type:Individual
Prefix:
First Name:SHIRLEY
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 1:790 VIA LATA STE 300
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3978
Mailing Address - Country:US
Mailing Address - Phone:909-433-0445
Mailing Address - Fax:909-494-7635
Practice Address - Street 1:790 VIA LATA STE 300
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3978
Practice Address - Country:US
Practice Address - Phone:909-433-0445
Practice Address - Fax:909-494-7635
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty