Provider Demographics
NPI:1932763539
Name:TRINITY HEALTH PROVIDER LLC
Entity Type:Organization
Organization Name:TRINITY HEALTH PROVIDER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENATO
Authorized Official - Middle Name:M
Authorized Official - Last Name:CUERVO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-518-8124
Mailing Address - Street 1:7331 N LINCOLN AVE STE 15
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-1766
Mailing Address - Country:US
Mailing Address - Phone:847-983-8356
Mailing Address - Fax:888-909-5815
Practice Address - Street 1:4756 N LAMON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3840
Practice Address - Country:US
Practice Address - Phone:224-518-8124
Practice Address - Fax:888-909-5815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty