Provider Demographics
NPI:1417043944
Name:RENFROW, BENJAMIN MACON (MSPT)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:MACON
Last Name:RENFROW
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 LAMONTE LANE
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77018
Mailing Address - Country:US
Mailing Address - Phone:713-628-1780
Mailing Address - Fax:713-838-2238
Practice Address - Street 1:1730 LAMONTE LANE
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018
Practice Address - Country:US
Practice Address - Phone:713-628-1780
Practice Address - Fax:713-838-2238
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
TX1150587225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J3176Medicare PIN