Provider Demographics
NPI:1871654616
Name:POLUCHA, MARY ANNE (DC)
Entity Type:Individual
Prefix:
First Name:MARY ANNE
Middle Name:
Last Name:POLUCHA
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 1:13450 DONNER PASS RD APT A
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96161-3889
Mailing Address - Country:US
Mailing Address - Phone:775-225-0380
Mailing Address - Fax:530-323-3832
Practice Address - Street 1:13450 DONNER PASS RD
Practice Address - Street 2:A
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-0456
Practice Address - Country:US
Practice Address - Phone:530-582-1228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2022-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20859111N00000X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U25589Medicare UPIN
NVV36474Medicare ID - Type UnspecifiedMC PART B