Provider Demographics
NPI:1386318624
Name:POLYDOR, MARIE
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:POLYDOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 CRIMSON CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32808-2202
Mailing Address - Country:US
Mailing Address - Phone:407-413-4337
Mailing Address - Fax:
Practice Address - Street 1:4504 CRIMSON CT
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32808-2202
Practice Address - Country:US
Practice Address - Phone:407-413-4337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL845281Medicaid