Provider Demographics
NPI:1780288142
Name:CASTILLO POLANCO, JESUS ALBERTO (FNC)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:ALBERTO
Last Name:CASTILLO POLANCO
Suffix:
Gender:M
Credentials:FNC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20100 PARK ROW DR APT 2102
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-4989
Mailing Address - Country:US
Mailing Address - Phone:832-941-2129
Mailing Address - Fax:832-626-3627
Practice Address - Street 1:1830 SNAKE RIVER RD STE D
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-1843
Practice Address - Country:US
Practice Address - Phone:863-812-6228
Practice Address - Fax:832-626-3627
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-25
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty