Healthcare Provider Details

I. General information

NPI: 1407799059
Provider Name (Legal Business Name): MANUEL POLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8621 LAWSON ST
EL PASO TX
79904-1992
US

IV. Provider business mailing address

8621 LAWSON ST
EL PASO TX
79904-1992
US

V. Phone/Fax

Practice location:
  • Phone: 915-272-6772
  • Fax:
Mailing address:
  • Phone: 915-272-6772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2026-0015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: