Healthcare Provider Details

I. General information

NPI: 1639620685
Provider Name (Legal Business Name): LAURENT E WANNER CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 10/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NORTHCREST DR STE 3
CRESCENT CITY CA
95531-2317
US

IV. Provider business mailing address

1000 NORTHCREST DR STE 3
CRESCENT CITY CA
95531-2317
US

V. Phone/Fax

Practice location:
  • Phone: 707-465-4132
  • Fax: 707-465-4132
Mailing address:
  • Phone: 707-465-4132
  • Fax: 707-465-4132

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC020025
License Number StateCA

VIII. Authorized Official

Name: DR. LAURENT E WANNER
Title or Position: DOCTOR OF CHIROPRACTIC
Credential: D.C.
Phone: 707-465-4132