=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538564828
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TYLER MANESS PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2014
-----------------------------------------------------
Last Update Date | 10/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 SUGAR MAPLE LN
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63303-5740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-946-8887
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 SUGAR MAPLE LN
-----------------------------------------------------
City | SAINT CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63303-5740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2011032386
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------