Provider Demographics
NPI:1538417381
Name:SHANA L BALLOW DO INC
Entity type:Organization
Organization Name:SHANA L BALLOW DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:BALLOW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:818-640-3552
Mailing Address - Street 1:2730 WILSHIRE BVLD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-4751
Mailing Address - Country:US
Mailing Address - Phone:626-768-4415
Mailing Address - Fax:626-403-0321
Practice Address - Street 1:1044 S FAIR OAKS AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2622
Practice Address - Country:US
Practice Address - Phone:626-768-4415
Practice Address - Fax:626-403-0321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-28
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A102992086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma SurgeryGroup - Single Specialty