Provider Demographics
NPI:1093892697
Name:WANNER, LAURENT EDWARD (DC)
Entity Type:Individual
Prefix:MR
First Name:LAURENT
Middle Name:EDWARD
Last Name:WANNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 NORTHCREST DR STE 3
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-2317
Mailing Address - Country:US
Mailing Address - Phone:707-465-4132
Mailing Address - Fax:707-465-4132
Practice Address - Street 1:1000 NORTHCREST DR STE 3
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-2317
Practice Address - Country:US
Practice Address - Phone:707-465-4132
Practice Address - Fax:707-465-4132
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0020025111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0100XChiropractic ProvidersChiropractorOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0200250Medicaid
CADC0200250Medicare ID - Type UnspecifiedMEDICARE #
CADC0200250Medicaid
CAU088402Medicare UPIN