Provider Demographics
NPI:1407999857
Name:LAURENTS, JOHN MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARK
Last Name:LAURENTS
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 1:815 E RECTOR ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-5931
Mailing Address - Country:US
Mailing Address - Phone:210-625-4828
Mailing Address - Fax:210-625-4834
Practice Address - Street 1:815 E RECTOR ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5931
Practice Address - Country:US
Practice Address - Phone:210-625-4828
Practice Address - Fax:210-625-4834
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4686111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0054262OtherBLUE LINK
TX2021601Medicaid
TX605845OtherBLUE CROSS BLUE SHIELD TX
TX377206300OtherFEDERAL ACS OWCP
TX601887Medicare ID - Type Unspecified
TX2021601Medicaid