Provider Demographics
NPI:1679598106
Name:FENTON, LARRY M JR (DC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:M
Last Name:FENTON
Suffix:JR
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 1:3740 COLONY DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-2234
Mailing Address - Country:US
Mailing Address - Phone:210-699-8153
Mailing Address - Fax:210-699-8299
Practice Address - Street 1:3740 COLONY DR
Practice Address - Street 2:SUITE 150
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-2234
Practice Address - Country:US
Practice Address - Phone:210-699-8153
Practice Address - Fax:210-699-8299
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8684111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S5430OtherBLUE CROSS BLUE SHIELD
TX609449Medicare PIN