Provider Demographics
NPI:1720733165
Name:RENTFROW, MARK ALLEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:RENTFROW
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 FOLLY RD STE 107
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2507
Practice Address - Country:US
Practice Address - Phone:843-762-0147
Practice Address - Fax:843-762-0421
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC225100000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC11116OtherSTATE LICENSE