Provider Demographics
NPI:1972259646
Name:MANION, TYLER JEFFREY (LAT, ATC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JEFFREY
Last Name:MANION
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 AUTUMN CREEK DR APT J
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:MO
Mailing Address - Zip Code:63088-2435
Mailing Address - Country:US
Mailing Address - Phone:618-799-8703
Mailing Address - Fax:
Practice Address - Street 1:701 S NEW BALLAS RD STE 510
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8726
Practice Address - Country:US
Practice Address - Phone:618-799-8703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960054762255A2300X
MO20220343952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer