Healthcare Provider Details

I. General information

NPI: 1295524544
Provider Name (Legal Business Name): ISAIAH POLSTRA
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2025
Last Update Date: 05/03/2025
Certification Date: 05/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 BOWLING GREEN DR
SACRAMENTO CA
95815-4101
US

IV. Provider business mailing address

5318 LONG CANYON DR
FAIR OAKS CA
95628-4181
US

V. Phone/Fax

Practice location:
  • Phone: 916-880-0272
  • Fax:
Mailing address:
  • Phone: 916-880-0272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: