Provider Demographics
NPI:1962622167
Name:POLAND, LARRY E (DC)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:E
Last Name:POLAND
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1828
Mailing Address - Street 2:
Mailing Address - City:BIG BEAR LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:92315-1828
Mailing Address - Country:US
Mailing Address - Phone:909-866-2100
Mailing Address - Fax:909-866-8731
Practice Address - Street 1:41656 BIG BEAR BLVD
Practice Address - Street 2:
Practice Address - City:BIG BEAR LAKE
Practice Address - State:CA
Practice Address - Zip Code:92315
Practice Address - Country:US
Practice Address - Phone:909-866-2100
Practice Address - Fax:909-866-8731
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0122520111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADCO122520Medicare UPIN
CA20050815Medicare ID - Type Unspecified