Provider Demographics
NPI:1073920559
Name:RENFRO, MICHAEL (AT-C, MA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:RENFRO
Suffix:
Gender:M
Credentials:AT-C, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1006 COLONIAL DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-1938
Mailing Address - Country:US
Mailing Address - Phone:727-776-5153
Mailing Address - Fax:
Practice Address - Street 1:5701 STILLWATER BLVD N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082-1030
Practice Address - Country:US
Practice Address - Phone:651-351-8034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC15172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer