Myofascial Release of Southern Illinois

Primary specialty

Rehabilitation Clinic/CenterTaxonomy code 261QR0400X

License

248.000873 Issued in IL

Legal business name

MYOFASCIAL RELEASE OF SOUTHERN ILLINOIS

Practice address

101 S Graham Ave
Suite 3
Carbondale, IL 62901-3043

Phone

(618) 305-4696

Fax

(888) 975-0097

NPI assigned

Nov 27, 2013

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tara Manzano, OTR/LNPI 1164853255

Title

President/Occupational Therapist

Phone

(618) 305-4696

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in IL

Enrollment records 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Tara Manzano, OTR/L

  • Occupational Therapist
  • Carbondale, IL
  • NPI 1164853255
  Medicare reassignment Care Compare group NPD Authorized official
• Eric Manzano, P.T.

  • Physical Therapist
  • Carbondale, IL
  • NPI 1356591895
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1385510400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1415059200000",
    "number": "1851722946",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "101 S GRAHAM AVE",
            "address_2": "SUITE 3",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629013043",
            "telephone_number": "618-305-4696",
            "fax_number": "888-975-0097"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "101 S GRAHAM AVE",
            "address_2": "SUITE 3",
            "city": "CARBONDALE",
            "state": "IL",
            "postal_code": "629013043",
            "telephone_number": "618-305-4696",
            "fax_number": "888-975-0097"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MYOFASCIAL RELEASE OF SOUTHERN ILLINOIS",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-11-27",
        "last_updated": "2014-11-04",
        "status": "A",
        "authorized_official_last_name": "MANZANO",
        "authorized_official_first_name": "TARA",
        "authorized_official_title_or_position": "PRESIDENT/OCCUPATIONAL THERAPIST",
        "authorized_official_telephone_number": "618-305-4696",
        "authorized_official_credential": "OTR/L"
    },
    "taxonomies": [
        {
            "code": "261QR0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rehabilitation",
            "state": "IL",
            "license": "248.000873",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Donald Mullison
• Mutaz Musa, M.D.
• Diane Muzio, M.S., CCC, SLP
• Deshera Myers
• Wendy Thein Myint
• Monica L Nagele, NP
• Kristen Nagreski
• Kyaw T Naing, M.D., PH.D.
• Ryan Nankervis
• Lisa A Nation, FNP

• Rehabilitation Clinic/Center in Carbondale, IL
• Providers in Carbondale, IL by specialty
• Rehabilitation Clinic/Center in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 4, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.