MEDICARE: MODERN MOLECULAR IMAGING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207UN0901X	Nuclear Cardiology Physician

General Provider Information

NPI Number	:	1700418738
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN MOLECULAR IMAGING LLC

Provider Business Mailing Address
First Line	:	7210 N MILBURN AVE STE 106
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93722-8449
Country	:	US
Telephone Number	:	702-817-0375
Fax Number	:

Provider Business Practice Location Address
First Line	:	7210 N MILBURN AVE STE 106
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93722-8449
Country	:	US
Telephone Number	:	702-817-0375
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JAMES BALLOW
Credential	:
Telephone Number	:	702-817-0375

Provider Enumeration Date	:	02/07/2020
Last Update Date	:	02/07/2020

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