Basic Information
| Provider Information | |||||||||
| NPI: | 1992759948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANNING | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 DEWEY AVE NW | ||||||||
| Address2: | STE 300 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495047335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163565000 | ||||||||
| FaxNumber: | 6163565000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1096 TOM GINNEVER AVE | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633664519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369785255 | ||||||||
| FaxNumber: | 6369785287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 02/06/2017 | ||||||||
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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 | 225100000X | 2001009061 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | P00602663 | 01 | MO | RAILROAD MEDICARE | OTHER |