Healthcare Provider Details

I. General information

NPI: 1396948402
Provider Name (Legal Business Name): VICTOR VANCE CARLOCK NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NOLAN TRACE
LEESVILLE LA
71446
US

IV. Provider business mailing address

1100 NOLAN TRACE
LEESVILLE LA
71446
US

V. Phone/Fax

Practice location:
  • Phone: 337-238-5180
  • Fax: 318-759-0828
Mailing address:
  • Phone: 337-238-5180
  • Fax: 337-238-4840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP05193
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP05193
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP05193
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: