Provider Demographics
NPI:1427024926
Name:MANZO, GEOFRY D (ATC)
Entity Type:Individual
Prefix:MR
First Name:GEOFRY
Middle Name:D
Last Name:MANZO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3002 CELEBRATION PARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 W LINCOLN ST
Practice Address - Street 2:SUITE 210
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1901
Practice Address - Country:US
Practice Address - Phone:618-641-5800
Practice Address - Fax:618-641-5825
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001527212255A2300X
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer