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 1:1624 W RIALTO AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-1924
Mailing Address - Country:US
Mailing Address - Phone:760-881-2660
Mailing Address - Fax:
Practice Address - Street 1:1738 N WATERMAN AVE STE 1AND2
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5131
Practice Address - Country:US
Practice Address - Phone:909-693-3302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty