Basic Information
| Provider Information | |||||||||
| NPI: | 1922417724 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | POLANCO | ||||||||
| FirstName: | TARA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 227 ANDOVER ST | ||||||||
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| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941105609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154251026 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7320 SW HUNZIKER ST | ||||||||
| Address2: | |||||||||
| City: | TIGARD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972238283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883171019 | ||||||||
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| ProviderEnumerationDate: | 08/05/2014 | ||||||||
| LastUpdateDate: | 08/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1074926 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 161216796 | 01 | OR | 22 RESPIRATORY, DEVELOPMENTAL, REHABILITATIVE AND RESTORATIVE SERVICE PROVIDERS | OTHER | 22 | 01 | CA | 22 RESPIRATORY, DEVELOPMENTAL, REHABILITATIVE AND RESTORATIVE SERVICE PROVIDERS | OTHER |