Healthcare Provider Details

I. General information

NPI: 1164939179
Provider Name (Legal Business Name): LUKAS DOMINIC MANIERI ATC, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TRINITY LN STE 111
BLOOMINGTON IL
61704-8112
US

IV. Provider business mailing address

1226 AIRPORT RD
BLOOMINGTON IL
61704-2522
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-6461
  • Fax: 309-663-5711
Mailing address:
  • Phone: 847-875-6849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096004560
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number16-06-30
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: