Provider Demographics
NPI:1306938493
Name:MACK, BRENT D (PT)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:MACK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25731 MEADOWLAND CIR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-2830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4334 FOX VALLEY CENTER DR
Practice Address - Street 2:SUITE C
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-7945
Practice Address - Country:US
Practice Address - Phone:630-236-7544
Practice Address - Fax:630-236-7574
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-012918225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK09921Medicare PIN
ILK53194Medicare PIN
ILR03918Medicare PIN
ILR02826Medicare PIN