Provider Demographics
NPI:1730471442
Name:POLO, SUZANNE (MS,RD, CLT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:
Last Name:POLO
Suffix:
Gender:F
Credentials:MS,RD, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4035
Mailing Address - Street 2:
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90264-4035
Mailing Address - Country:US
Mailing Address - Phone:917-548-5480
Mailing Address - Fax:
Practice Address - Street 1:33461 PACIFIC COAST HWY
Practice Address - Street 2:
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-2308
Practice Address - Country:US
Practice Address - Phone:917-548-5480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered