Basic Information
| Provider Information | |||||||||
| NPI: | 1316057490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RENTH | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | LEE | ||||||||
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| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIFFIN | ||||||||
| OtherFirstName: | MICHELE | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1131 FOX RUN | ||||||||
| Address2: | |||||||||
| City: | MASCOUTAH | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185668740 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5900 N ILLINOIS | ||||||||
| Address2: | SUITE 9 | ||||||||
| City: | FAIRVIEW HEIGHTS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3146211416 | ||||||||
| FaxNumber: | 6186249330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 104552 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.