MEDICARE: MR. MARIO POLANCO B.S, DEGREE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	PT 11680	CA
2	225100000X	Physical Therapist	11680	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20-5607292	OTHER	CA	TAX ID#

General Provider Information

NPI Number	:	1073640587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARIO POLANCO B.S, DEGREE

Provider Business Mailing Address
First Line	:	PO BOX 45195
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-0191
Country	:	US
Telephone Number	:	323-887-7458
Fax Number	:	323-887-8288

Provider Business Practice Location Address
First Line	:	5301 WHITTIER BLVD
Second Line	:	ATRIUM SUITE
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-4038
Country	:	US
Telephone Number	:	323-887-7458
Fax Number	:	323-887-8288

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2007
Last Update Date	:	12/22/2011

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