Provider Demographics
NPI:1952411092
Name:BANNOCK, LAURENT GRAHAM (DHSC LN)
Entity Type:Individual
Prefix:DR
First Name:LAURENT
Middle Name:GRAHAM
Last Name:BANNOCK
Suffix:
Gender:M
Credentials:DHSC LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CERRADO DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87508-8234
Mailing Address - Country:US
Mailing Address - Phone:505-310-1476
Mailing Address - Fax:505-982-8475
Practice Address - Street 1:3600 CERRILLOS RD
Practice Address - Street 2:SUITE 207C
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2612
Practice Address - Country:US
Practice Address - Phone:505-982-8475
Practice Address - Fax:505-989-7865
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMP-0037133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist