Provider Demographics
NPI:1255972303
Name:MCCOLLUM, WILLIAM LOUSHION
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:LOUSHION
Last Name:MCCOLLUM
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 1:831 GULF AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-4201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:831 GULF AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-4201
Practice Address - Country:US
Practice Address - Phone:424-533-8484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-30
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QV0200X
CA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAIDKMedicaid