Provider Demographics
NPI:1578993424
Name:DI RENZO, VINCENT JOHN (MAT,ATC,CSCS)
Entity Type:Individual
Prefix:MR
First Name:VINCENT
Middle Name:JOHN
Last Name:DI RENZO
Suffix:
Gender:M
Credentials:MAT,ATC,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13468 DELANEY RD
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-6334
Mailing Address - Country:US
Mailing Address - Phone:815-354-5667
Mailing Address - Fax:815-943-8008
Practice Address - Street 1:1783 RICHMOND AVENUE
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050
Practice Address - Country:US
Practice Address - Phone:815-385-0730
Practice Address - Fax:815-385-0572
Is Sole Proprietor?:No
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0036442255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer