Provider Demographics
NPI:1285469296
Name:LOUSTALOT, JOHN ALLEN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALLEN
Last Name:LOUSTALOT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1894
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70381-1894
Mailing Address - Country:US
Mailing Address - Phone:337-940-1139
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1894
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70381-1894
Practice Address - Country:US
Practice Address - Phone:337-940-1139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA011086626172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver