Provider Demographics
NPI:1972951614
Name:POLIS, MICHAEL VINCENT (REGISTERED DIETITIAN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:VINCENT
Last Name:POLIS
Suffix:
Gender:M
Credentials:REGISTERED DIETITIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MARTIN ARMY 6600 VAN AALST BLVD
Mailing Address - Street 2:BLD 9250
Mailing Address - City:FOR MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905
Mailing Address - Country:US
Mailing Address - Phone:762-408-1190
Mailing Address - Fax:
Practice Address - Street 1:MARTIN ARMY 6600
Practice Address - Street 2:9250
Practice Address - City:FORT MOORE
Practice Address - State:GA
Practice Address - Zip Code:31905
Practice Address - Country:US
Practice Address - Phone:762-408-2033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2254133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered