Provider Demographics
NPI:1164939179
Name:MANIERI, LUKAS DOMINIC (ATC, OTC)
Entity Type:Individual
Prefix:
First Name:LUKAS
Middle Name:DOMINIC
Last Name:MANIERI
Suffix:
Gender:M
Credentials:ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2522
Mailing Address - Country:US
Mailing Address - Phone:847-875-6849
Mailing Address - Fax:
Practice Address - Street 1:1111 TRINITY LN STE 111
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8112
Practice Address - Country:US
Practice Address - Phone:309-663-6461
Practice Address - Fax:309-663-5711
Is Sole Proprietor?:No
Enumeration Date:2017-12-29
Last Update Date:2017-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16-06-30246ZX2200X
IL0960045602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant