Healthcare Provider Details

I. General information

NPI: 1952411092
Provider Name (Legal Business Name): LAURENT GRAHAM BANNOCK DHSC LN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 CERRILLOS RD SUITE 207C
SANTA FE NM
87507-2612
US

IV. Provider business mailing address

9 CERRADO DR
SANTA FE NM
87508-8234
US

V. Phone/Fax

Practice location:
  • Phone: 505-982-8475
  • Fax: 505-989-7865
Mailing address:
  • Phone: 505-310-1476
  • Fax: 505-982-8475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberP-0037
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: