Basic Information
| Provider Information | |||||||||
| NPI: | 1578993424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DI RENZO | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MAT,ATC,CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13468 DELANEY RD | ||||||||
| Address2: | |||||||||
| City: | HUNTLEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601426334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153545667 | ||||||||
| FaxNumber: | 8159438008 | ||||||||
| Practice Location | |||||||||
| Address1: | 1783 RICHMOND AVENUE | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153850730 | ||||||||
| FaxNumber: | 8153850572 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2013 | ||||||||
| LastUpdateDate: | 11/13/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 096.003644 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.