Healthcare Provider Details

I. General information

NPI: 1538417381
Provider Name (Legal Business Name): SHANA L BALLOW DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 S FAIR OAKS AVE SUITE 101
PASADENA CA
91105-2622
US

IV. Provider business mailing address

2730 WILSHIRE BVLD SUITE 400
SANTA MONICA CA
90403-4751
US

V. Phone/Fax

Practice location:
  • Phone: 626-768-4415
  • Fax: 626-403-0321
Mailing address:
  • Phone: 626-768-4415
  • Fax: 626-403-0321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number20A10299
License Number StateCA

VIII. Authorized Official

Name: DR. SHANA LYNN BALLOW
Title or Position: PRESIDENT
Credential: DO
Phone: 818-640-3552