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NPI Code Detail

MEDICARE: TYLER JEFFREY MANION LAT, ATC

MEDICARE: TYLER JEFFREY MANION LAT, ATC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12255A2300XAthletic Trainer096005476IL
22255A2300XAthletic Trainer2022034395MO

General Provider Information

NPI Number : 1972259646
Entity Type Code : Individual
Provider Name (Legal Business Name) : TYLER JEFFREY MANION LAT, ATC
Provider Business Mailing Address
First Line : 378 AUTUMN CREEK DR APT J
Second Line :
City : MANCHESTER
State : MO
Zip : 63088-2435
Country : US
Telephone Number : 618-799-8703
Fax Number :
Provider Business Practice Location Address
First Line : 701 S NEW BALLAS RD STE 510
Second Line :
City : SAINT LOUIS
State : MO
Zip : 63141-8726
Country : US
Telephone Number : 618-799-8703
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/22/2022
Last Update Date : 05/13/2024

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