Organization
MYOFASCIAL RELEASE OF SOUTHERN ILLINOIS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TARA MANZANO OTR/L (PRESIDENT/OCCUPATIONAL THERAPIST)
(618) 305-4696
Entity
Organization
Contact information
Practice address
101 S GRAHAM AVE, SUITE 3, CARBONDALE, IL 62901-3043
(618) 305-4696
(888) 975-0097
Mailing address
101 S GRAHAM AVE, SUITE 3, CARBONDALE, IL 62901-3043
(618) 305-4696
(888) 975-0097
Taxonomy
Speciality
Code
Description
License number
State
261QR0400X
Rehabilitation Clinic/Center
Primary
248.000873
IL
Other
Enumeration date
11/27/2013
Last updated
11/04/2014
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