Healthcare Provider Details

I. General information

NPI: 1598687717
Provider Name (Legal Business Name): CRESCENT CITY SURGICAL CENTRE DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 VETERANS MEMORIAL DR
KOSCIUSKO MS
39090-3854
US

IV. Provider business mailing address

735 VETERANS MEMORIAL DR
KOSCIUSKO MS
39090-3854
US

V. Phone/Fax

Practice location:
  • Phone: 662-803-6086
  • Fax: 504-504-5211
Mailing address:
  • Phone: 662-803-6086
  • Fax: 504-504-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM LAWRENCE BOUCHILLON JR.
Title or Position: CEO
Credential: MR.
Phone: 662-803-6086