Provider Demographics
NPI:1790304707
Name:NICOLLETTE L. BALLOU, M.D.
Entity Type:Organization
Organization Name:NICOLLETTE L. BALLOU, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLETTE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BALLOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-659-7867
Mailing Address - Street 1:3831 HUGHES AVE STE 602
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6845
Mailing Address - Country:US
Mailing Address - Phone:310-659-7867
Mailing Address - Fax:310-878-2118
Practice Address - Street 1:3831 HUGHES AVE STE 602
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-6845
Practice Address - Country:US
Practice Address - Phone:310-659-7867
Practice Address - Fax:310-878-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1457420077Medicaid