Provider Demographics
NPI:1891155255
Name:ACOSTA, RIGOBERTO
Entity Type:Individual
Prefix:
First Name:RIGOBERTO
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 N WESTERN AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3723
Mailing Address - Country:US
Mailing Address - Phone:773-531-8262
Mailing Address - Fax:
Practice Address - Street 1:5517 N KENMORE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1515
Practice Address - Country:US
Practice Address - Phone:773-275-7962
Practice Address - Fax:773-561-5497
Is Sole Proprietor?:No
Enumeration Date:2016-02-28
Last Update Date:2016-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.119637164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1932318920Medicaid