Provider Demographics
NPI:1831540962
Name:POLCHAK, LORRAINE
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:POLCHAK
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 1:4718 N ELIZABETH ST STE A
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2080
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4718 N ELIZABETH ST STE A
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2080
Practice Address - Country:US
Practice Address - Phone:719-544-5895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA0012060225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant