Provider Demographics
NPI:1104090950
Name:HERNANDEZ, POLLY
Entity type:Individual
Prefix:
First Name:POLLY
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SILAS
Other - Middle Name:MEDICAL
Other - Last Name:SERVICES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:513 1/2 E MANCHESTER BLVD
Mailing Address - Street 2:#202
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1907
Mailing Address - Country:US
Mailing Address - Phone:310-673-9193
Mailing Address - Fax:310-673-9195
Practice Address - Street 1:513 1/2 E MANCHESTER BLVD
Practice Address - Street 2:#202
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1907
Practice Address - Country:US
Practice Address - Phone:310-673-9193
Practice Address - Fax:310-673-9195
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA557429Medicare Oscar/Certification