Basic Information
| Provider Information | |||||||||
| NPI: | 1164939179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANIERI | ||||||||
| FirstName: | LUKAS | ||||||||
| MiddleName: | DOMINIC | ||||||||
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| Credential: | ATC, OTC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1226 AIRPORT RD | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617042522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478756849 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1111 TRINITY LN STE 111 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617048112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096636461 | ||||||||
| FaxNumber: | 3096635711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2017 | ||||||||
| LastUpdateDate: | 12/29/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZX2200X | 16-06-30 | IL | N | 2255A2300X | 096004560 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.