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General NPI Number Information
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NPI Number | 1790304707
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Entity Type | Organization
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Legal Business Name | NICOLLETTE L. BALLOU, M.D.
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Dates
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Enumeration Date | 04/09/2020
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Last Update Date | 04/09/2020
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Provider Practice Location Address
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Address Line | 3831 HUGHES AVE STE 602
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City | CULVER CITY
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State | CA
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Zip | 90232-6845
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Country | US
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Telephone | 310-659-7867
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Fax | 310-878-2118
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Provider Business Mailing Address
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Address Line | 3831 HUGHES AVE STE 602
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City | CULVER CITY
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State | CA
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Zip | 90232-6845
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Country | US
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Telephone | 310-659-7867
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Fax | 310-878-2118
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Authorized Official
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Title or Position | CEO
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Name | NICOLETTE LEE BALLOU
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Credential | MD
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Telephone | 310-659-7867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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