Provider Demographics
NPI:1770632127
Name:WILNER, LAWRENCE MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:MICHAEL
Last Name:WILNER
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 1:3 CORPORATE DRIVE
Mailing Address - Street 2:SUITE 160
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484
Mailing Address - Country:US
Mailing Address - Phone:203-929-5500
Mailing Address - Fax:203-926-1220
Practice Address - Street 1:3 CORPORATE DRIVE
Practice Address - Street 2:SUITE 160
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484
Practice Address - Country:US
Practice Address - Phone:203-929-5500
Practice Address - Fax:203-926-1220
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000862111N00000X, 111NR0400X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered111NR0400XChiropractic ProvidersChiropractorRehabilitation
Not Answered225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT050000862CT01OtherANTHEM BCBS
CTCV2880OtherHEALTHNET LANDMARK
U20119Medicare UPIN