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General NPI Number Information
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NPI Number | 1083617237
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Entity Type | Organization
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Legal Business Name | M A CULASSO, LLC
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Dates
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Enumeration Date | 05/23/2005
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Last Update Date | 04/05/2011
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Provider Practice Location Address
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Address Line | 1520 GAUSE BLVD
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City | SLIDELL
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State | LA
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Zip | 70458-2208
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Country | US
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Telephone | 985-649-0945
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Fax | 985-643-8510
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Provider Business Mailing Address
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Address Line | PO BOX 729
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City | SLIDELL
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State | LA
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Zip | 70459-0729
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Country | US
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Telephone | 985-646-0945
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Fax | 985-643-8510
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | MR. MIGUEL A CULASSO
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Credential | MD
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Telephone | 985-646-0945
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 013032
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License Number State | LA
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