Provider Demographics
NPI:1851722946
Name:MYOFASCIAL RELEASE OF SOUTHERN ILLINOIS
Entity Type:Organization
Organization Name:MYOFASCIAL RELEASE OF SOUTHERN ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANZANO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:618-305-4696
Mailing Address - Street 1:101 S GRAHAM AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-3043
Mailing Address - Country:US
Mailing Address - Phone:618-305-4696
Mailing Address - Fax:888-975-0097
Practice Address - Street 1:101 S GRAHAM AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3043
Practice Address - Country:US
Practice Address - Phone:618-305-4696
Practice Address - Fax:888-975-0097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-27
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL248.000873261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation