Healthcare Provider Details

I. General information

NPI: 1679653596
Provider Name (Legal Business Name): MARIANA POLANCO L.S.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1086 TEANECK RD
TEANECK NJ
07666-4854
US

IV. Provider business mailing address

21109 42ND AVE APT 1C
BAYSIDE NY
11361-2807
US

V. Phone/Fax

Practice location:
  • Phone: 281-703-2929
  • Fax:
Mailing address:
  • Phone: 281-703-2929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License NumberSA00278
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number03-162
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: