Healthcare Provider Details

I. General information

NPI: 1073193579
Provider Name (Legal Business Name): MODERN NUCLEAR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 04/09/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 S HARBOR BLVD STE E
LA HABRA CA
90631-9375
US

IV. Provider business mailing address

511 S HARBOR BLVD STE E
LA HABRA CA
90631-9375
US

V. Phone/Fax

Practice location:
  • Phone: 562-905-2244
  • Fax: 562-905-2024
Mailing address:
  • Phone: 562-905-2244
  • Fax: 562-905-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471N0900X
TaxonomyNuclear Medicine Technology Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: MR. PATRICK J LAVERTY
Title or Position: CEO/RSO
Credential: CNMT
Phone: 562-905-2244