Healthcare Provider Details

I. General information

NPI: 1508776170
Provider Name (Legal Business Name): VICTORIA GOODWIN POLANCO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

226 S IVY AVE
MONROVIA CA
91016-2836
US

IV. Provider business mailing address

447 N ROCKVALE AVE
AZUSA CA
91702-3851
US

V. Phone/Fax

Practice location:
  • Phone: 626-471-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number530BC02966
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: