Basic Information
| Provider Information | |||||||||
| NPI: | 1891155255 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ACOSTA | ||||||||
| FirstName: | RIGOBERTO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3800 N WESTERN AVE | ||||||||
| Address2: | APT 2 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606183723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735318262 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5517 N KENMORE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606401515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732757962 | ||||||||
| FaxNumber: | 7735615497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2016 | ||||||||
| LastUpdateDate: | 02/28/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 043.119637 | IL | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 1932318920 | 05 | IL | MEDICAID |