Healthcare Provider Details

I. General information

NPI: 1790304707
Provider Name (Legal Business Name): NICOLLETTE L. BALLOU, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3831 HUGHES AVE STE 602
CULVER CITY CA
90232-6845
US

IV. Provider business mailing address

3831 HUGHES AVE STE 602
CULVER CITY CA
90232-6845
US

V. Phone/Fax

Practice location:
  • Phone: 310-659-7867
  • Fax: 310-878-2118
Mailing address:
  • Phone: 310-659-7867
  • Fax: 310-878-2118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLETTE LEE BALLOU
Title or Position: CEO
Credential: MD
Phone: 310-659-7867