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General NPI Number Information
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NPI Number | 1851722946
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Entity Type | Organization
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Legal Business Name | MYOFASCIAL RELEASE OF SOUTHERN ILLINOIS
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Dates
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Enumeration Date | 11/27/2013
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Last Update Date | 11/04/2014
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Provider Practice Location Address
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Address Line | 101 S GRAHAM AVE SUITE 3
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City | CARBONDALE
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State | IL
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Zip | 62901-3043
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Country | US
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Telephone | 618-305-4696
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Fax | 888-975-0097
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Provider Business Mailing Address
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Address Line | 101 S GRAHAM AVE SUITE 3
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City | CARBONDALE
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State | IL
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Zip | 62901-3043
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Country | US
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Telephone | 618-305-4696
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Fax | 888-975-0097
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Authorized Official
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Title or Position | PRESIDENT/OCCUPATIONAL THERAPIST
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Name | TARA MANZANO
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Credential | OTR/L
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Telephone | 618-305-4696
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number | 248.000873
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License Number State | IL
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