Provider Demographics
NPI:1124712179
Name:RENOVARE HEALTHCARE SERVICES INC
Entity type:Organization
Organization Name:RENOVARE HEALTHCARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUMIDE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:ANP
Authorized Official - Phone:773-392-1858
Mailing Address - Street 1:6818 N LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLNWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60712-4728
Mailing Address - Country:US
Mailing Address - Phone:773-392-1858
Mailing Address - Fax:
Practice Address - Street 1:5875 N LINCOLN AVE STE 224
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-4668
Practice Address - Country:US
Practice Address - Phone:773-392-1858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-05
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty