Provider Demographics
NPI:1720543697
Name:BRENT, MARCUS A (LMT)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:A
Last Name:BRENT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7452 WARREN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1506
Mailing Address - Country:US
Mailing Address - Phone:773-370-2250
Mailing Address - Fax:
Practice Address - Street 1:263 N YORK ST STE 202
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2758
Practice Address - Country:US
Practice Address - Phone:312-468-6674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist