MEDICARE: GUADALUPE LIZETH POLANCO LMT

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	225700000X	Massage Therapist	99859	FL

General Provider Information

NPI Number	:	1346091931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUADALUPE LIZETH POLANCO LMT

Provider Business Mailing Address
First Line	:	13217 LAKE YALE VIEW LOOP
Second Line	:
City	:	GRAND ISLAND
State	:	FL
Zip	:	32735-8967
Country	:	US
Telephone Number	:	323-449-2518
Fax Number	:

Provider Business Practice Location Address
First Line	:	1416 N DONNELLY ST
Second Line	:
City	:	MOUNT DORA
State	:	FL
Zip	:	32757-2814
Country	:	US
Telephone Number	:	407-476-7497
Fax Number	:

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

Provider Enumeration Date	:	04/01/2024
Last Update Date	:	04/01/2024

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