Healthcare Provider Details

I. General information

NPI: 1285569905
Provider Name (Legal Business Name): DIEGO ANDRES POLANCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 WESTHALL LN STE 150
MAITLAND FL
32751-7476
US

IV. Provider business mailing address

1452 KILLIAN DR NE
PALM BAY FL
32905-4446
US

V. Phone/Fax

Practice location:
  • Phone: 407-810-5433
  • Fax: 407-386-3198
Mailing address:
  • Phone: 321-305-0889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: