Provider Demographics
NPI:1629185574
Name:POLANCO, KACEY D (MPT)
Entity type:Individual
Prefix:
First Name:KACEY
Middle Name:D
Last Name:POLANCO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N DATE ST
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-1748
Mailing Address - Country:US
Mailing Address - Phone:575-894-1828
Mailing Address - Fax:575-894-6873
Practice Address - Street 1:910 N DATE ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-1748
Practice Address - Country:US
Practice Address - Phone:575-894-1828
Practice Address - Fax:575-894-6873
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3167225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM39531864Medicaid
NM349535104Medicare PIN