Provider Demographics
NPI:1801072970
Name:RENACER LATINO INC.
Entity type:Organization
Organization Name:RENACER LATINO INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUZ
Authorized Official - Middle Name:R
Authorized Official - Last Name:GVERO
Authorized Official - Suffix:
Authorized Official - Credentials:MISA II, CADC
Authorized Official - Phone:847-336-7302
Mailing Address - Street 1:620 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085-5421
Mailing Address - Country:US
Mailing Address - Phone:847-336-7302
Mailing Address - Fax:
Practice Address - Street 1:620 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-5421
Practice Address - Country:US
Practice Address - Phone:847-336-7302
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-18
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL897251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04932522OtherBLUE CROSS BLUE SHIELD