Healthcare Provider Details

I. General information

NPI: 1104400241
Provider Name (Legal Business Name): MYCNA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3309 BERNARD ST
LA PORTE TX
77571-3827
US

IV. Provider business mailing address

3309 BERNARD ST
LA PORTE TX
77571-3827
US

V. Phone/Fax

Practice location:
  • Phone: 281-383-0017
  • Fax:
Mailing address:
  • Phone: 281-383-0017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: RAUL A FLORES
Title or Position: OWNER
Credential:
Phone: 281-383-0017