Healthcare Provider Details

I. General information

NPI: 1598251498
Provider Name (Legal Business Name): DAVID ALLEN POLSTRA ACNPC-AG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2018
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S GRAND AVE
LOS ANGELES CA
90015-3010
US

IV. Provider business mailing address

2127 CAMORILLA DR
LOS ANGELES CA
90065-3401
US

V. Phone/Fax

Practice location:
  • Phone: 213-748-2411
  • Fax:
Mailing address:
  • Phone: 323-907-9895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number95009210
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61493227
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: