Basic Information
Provider Information | |||||||||
NPI: | 1538417381 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SHANA L BALLOW DO INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2730 WILSHIRE BVLD | ||||||||
Address2: | SUITE 400 | ||||||||
City: | SANTA MONICA | ||||||||
State: | CA | ||||||||
PostalCode: | 904034751 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6267684415 | ||||||||
FaxNumber: | 6264030321 | ||||||||
Practice Location | |||||||||
Address1: | 1044 S FAIR OAKS AVE | ||||||||
Address2: | SUITE 101 | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911052622 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6267684415 | ||||||||
FaxNumber: | 6264030321 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/28/2012 | ||||||||
LastUpdateDate: | 08/31/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BALLOW | ||||||||
AuthorizedOfficialFirstName: | SHANA | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8186403552 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0127X | 20A10299 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
No ID Information.