1538305271 NPI number — SARA TERESA POLANCO OTR/L, DSC

Table of content: SARA TERESA POLANCO OTR/L, DSC (NPI 1538305271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538305271 NPI number — SARA TERESA POLANCO OTR/L, DSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLANCO
Provider First Name:
SARA
Provider Middle Name:
TERESA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR/L, DSC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538305271
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
950 BIG SKY DR
Provider Second Line Business Mailing Address:
APT E-304
Provider Business Mailing Address City Name:
CLARKSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37040-5273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-602-9441
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
650 JOEL DR
Provider Second Line Business Practice Location Address:
OCCUPATIONAL THERAPY DEPARTMENT
Provider Business Practice Location Address City Name:
FORT CAMPBELL
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42223-5318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-602-9441
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/31/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OT004542 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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