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General NPI Number Information
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NPI Number | 1679653596
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Entity Type | Individual
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Provider Name | MARIANA POLANCO L.S.A.
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Gender | Female
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Dates
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Enumeration Date | 10/16/2006
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Last Update Date | 05/01/2013
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Provider Practice Location Address
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Address Line | 1086 TEANECK RD
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City | TEANECK
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State | NJ
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Zip | 07666-4854
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Country | US
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Telephone | 281-703-2929
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Fax |
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Provider Business Mailing Address
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Address Line | 21109 42ND AVE APT 1C
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City | BAYSIDE
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State | NY
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Zip | 11361-2807
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Country | US
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Telephone | 281-703-2929
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246Z00000X
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Taxonomy Name | Other Specialist/Technologist
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License Number | SA00278
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 246ZE0600X
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Taxonomy Name | Electroneurodiagnostic Specialist/Technologist
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License Number | 03-162
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License Number State | IL
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