Basic Information
| Provider Information | |||||||||
| NPI: | 1114290632 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BALLANTYNE MEDICAL ASSOCIATES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104749809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12311 COPPER WAY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282773642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045401640 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2012 | ||||||||
| LastUpdateDate: | 02/14/2012 | ||||||||
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| AuthorizedOfficialLastName: | JORGE | ||||||||
| AuthorizedOfficialFirstName: | CARLOS | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7045401640 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BALLANTYNE MEDICAL ASSOCIATES PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.