MEDICARE: MRS. ALISIA KAY POLZIN

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	156FX1800X	Optician	156798	UT

General Provider Information

NPI Number	:	1457543258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ALISIA KAY POLZIN

Provider Business Mailing Address
First Line	:	1485 E 3900 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1438
Country	:	US
Telephone Number	:	801-277-2062
Fax Number	:	801-274-3233

Provider Business Practice Location Address
First Line	:	1485 E 3900 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1438
Country	:	US
Telephone Number	:	801-277-2062
Fax Number	:	801-274-3233

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

Provider Enumeration Date	:	08/15/2007
Last Update Date	:	08/15/2007

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