Healthcare Provider Details

I. General information

NPI: 1669386512
Provider Name (Legal Business Name): RENATO VIGILIA NATIVIDAD JR. REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 S 5TH AVE
HINES IL
60141-3030
US

IV. Provider business mailing address

1309 ELLIOTT ST
PARK RIDGE IL
60068-1301
US

V. Phone/Fax

Practice location:
  • Phone: 708-894-5071
  • Fax:
Mailing address:
  • Phone: 773-340-8022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number041.396124
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: