Healthcare Provider Details

I. General information

NPI: 1659394047
Provider Name (Legal Business Name): MODERN NUCLEAR, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

511 S HARBOR BLVD BLDG 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 NumberRAML 5179-30
License Number StateCA

VIII. Authorized Official

Name: MR. PATRICK JAMES LAVERTY
Title or Position: C.E.O.
Credential: C.N.M.T., R.S.O.
Phone: 562-905-2244