Provider Demographics
NPI:1700418738
Name:MODERN MOLECULAR IMAGING LLC
Entity Type:Organization
Organization Name:MODERN MOLECULAR IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
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 1:7210 N MILBURN AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-8449
Mailing Address - Country:US
Mailing Address - Phone:702-817-0375
Mailing Address - Fax:
Practice Address - Street 1:7210 N MILBURN AVE STE 106
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-8449
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:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear CardiologyGroup - Single Specialty