Provider Demographics
NPI:1649204736
Name:HARVEY, WYNN TRAYLOR (DC)
Entity Type:Individual
Prefix:
First Name:WYNN
Middle Name:TRAYLOR
Last Name:HARVEY
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 1:1319 DONAHUE FERRY RD
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-5143
Mailing Address - Country:US
Mailing Address - Phone:318-443-7232
Mailing Address - Fax:318-443-5881
Practice Address - Street 1:1319 DONAHUE FERRY RD
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-5143
Practice Address - Country:US
Practice Address - Phone:318-443-7232
Practice Address - Fax:318-443-5881
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA908111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2919AOtherBLUE CROSS/BLUE SHIELD
LA2919AOtherBLUE CROSS/BLUE SHIELD
LA1649204736Medicare PIN
5S475Medicare ID - Type Unspecified