Healthcare Provider Details

I. General information

NPI: 1831178631
Provider Name (Legal Business Name): JOCELYN H LAROCQUE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15830 BALLANTYNE MEDICAL PL STE 100
CHARLOTTE NC
28277-4653
US

IV. Provider business mailing address

15830 BALLANTYNE MEDICAL PL STE 100
CHARLOTTE NC
28277-4653
US

V. Phone/Fax

Practice location:
  • Phone: 704-341-0090
  • Fax: 704-341-0092
Mailing address:
  • Phone: 704-341-0090
  • Fax: 704-341-0092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2005-00628
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number200500628
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: