Healthcare Provider Details

I. General information

NPI: 1154708105
Provider Name (Legal Business Name): MR. GARRETT LANE VICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 01/22/2026
Certification Date: 01/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 ENTERPRISE DR STE C
HOUMA LA
70360-5405
US

IV. Provider business mailing address

213 BELMERE LUXURY CT
HOUMA LA
70360-2960
US

V. Phone/Fax

Practice location:
  • Phone: 985-360-3755
  • Fax: 985-879-4580
Mailing address:
  • Phone: 903-272-7950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number302659
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: