Healthcare Provider Details

I. General information

NPI: 1689631426
Provider Name (Legal Business Name): MICHAEL ANDREW POLANDER P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 BENTON RD
BOSSIER CITY LA
71111-3603
US

IV. Provider business mailing address

925 BENTON RD
BOSSIER CITY LA
71111-3603
US

V. Phone/Fax

Practice location:
  • Phone: 318-747-4433
  • Fax: 318-747-4454
Mailing address:
  • Phone: 318-747-4433
  • Fax: 318-747-4454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-01015
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: