Provider Demographics
NPI:1225236235
Name:BULLOCK, LANCE EVERETT
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:EVERETT
Last Name:BULLOCK
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 1:37459 ULTIMA PLAZA BLVD STE B-227
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-3856
Mailing Address - Country:US
Mailing Address - Phone:225-673-8258
Mailing Address - Fax:225-673-2340
Practice Address - Street 1:3136 S SAINT LANDRY AVE
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5801
Practice Address - Country:US
Practice Address - Phone:225-647-7524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09761R2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1683728Medicaid
LA5U943CH16Medicare PIN