=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598687717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRESCENT CITY SURGICAL CENTRE DIAGNOSTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2026
-----------------------------------------------------
Last Update Date | 07/28/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 735 VETERANS MEMORIAL DR
-----------------------------------------------------
City | KOSCIUSKO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39090-3854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-803-6086
-----------------------------------------------------
Fax | 504-504-5211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 735 VETERANS MEMORIAL DR
-----------------------------------------------------
City | KOSCIUSKO
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39090-3854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-803-6086
-----------------------------------------------------
Fax | 504-504-5211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | WILLIAM LAWRENCE BOUCHILLON JR.
-----------------------------------------------------
Credential | MR.
-----------------------------------------------------
Telephone | 662-803-6086
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------