Provider Demographics
NPI:1629586458
Name:CARDIAC MOLECULAR PET IMAGING LLC
Entity Type:Organization
Organization Name:CARDIAC MOLECULAR PET IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-817-0375
Mailing Address - Street 1:5944 MAHOGANY MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89142-1685
Mailing Address - Country:US
Mailing Address - Phone:702-817-0375
Mailing Address - Fax:
Practice Address - Street 1:2030 FOREST AVE STE 110
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-4833
Practice Address - Country:US
Practice Address - Phone:702-817-0375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-15
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20161669909293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory