Provider Demographics
NPI:1477151884
Name:LAURENCEAU, JOEL
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:
Last Name:LAURENCEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2561 SW GROTTO CIR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2927
Mailing Address - Country:US
Mailing Address - Phone:786-333-7288
Mailing Address - Fax:
Practice Address - Street 1:2561 SW GROTTO CIR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2927
Practice Address - Country:US
Practice Address - Phone:786-333-7288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLL652-425-70-173-0OtherDRIVER LICENSE