Provider Demographics
NPI:1699118927
Name:POLAND, HENRY (COTA)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:POLAND
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11721 CLAY ANSLEY HWY
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-8257
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:740 DENTON FERRY RD
Practice Address - Street 2:
Practice Address - City:COTTER
Practice Address - State:AR
Practice Address - Zip Code:72626-9701
Practice Address - Country:US
Practice Address - Phone:318-548-0682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROT-A451172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker