Provider Demographics
NPI:1558500124
Name:MANTENO PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:MANTENO PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RYBA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:815-468-7300
Mailing Address - Street 1:19 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MANTENO
Mailing Address - State:IL
Mailing Address - Zip Code:60950-1533
Mailing Address - Country:US
Mailing Address - Phone:815-468-7300
Mailing Address - Fax:
Practice Address - Street 1:19 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1533
Practice Address - Country:US
Practice Address - Phone:815-468-7300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.008529174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty