Provider Demographics
NPI:1003449489
Name:MANUBAG, JOHN LORENZ LOYOLA (PT, DPT)
Entity Type:Individual
Prefix:
First Name:JOHN LORENZ
Middle Name:LOYOLA
Last Name:MANUBAG
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 KENNETH DR APT C
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-1742
Mailing Address - Country:US
Mailing Address - Phone:859-408-5775
Mailing Address - Fax:
Practice Address - Street 1:3900 SULLIVAN DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-7397
Practice Address - Country:US
Practice Address - Phone:618-234-8910
Practice Address - Fax:618-234-8920
Is Sole Proprietor?:No
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.024932225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist