MEDICARE: DR. LAURENT GRAHAM BANNOCK DHSC LN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist	P-0037	NM

General Provider Information

NPI Number	:	1952411092
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURENT GRAHAM BANNOCK DHSC LN

Provider Business Mailing Address
First Line	:	9 CERRADO DR
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87508-8234
Country	:	US
Telephone Number	:	505-310-1476
Fax Number	:	505-982-8475

Provider Business Practice Location Address
First Line	:	3600 CERRILLOS RD
Second Line	:	SUITE 207C
City	:	SANTA FE
State	:	NM
Zip	:	87507-2612
Country	:	US
Telephone Number	:	505-982-8475
Fax Number	:	505-989-7865

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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