MEDICARE: ST VOLTAIRE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1720775059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST VOLTAIRE INC

Provider Business Mailing Address
First Line	:	489 DEWDROP CIR APT C
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45240-3799
Country	:	US
Telephone Number	:	513-975-9216
Fax Number	:

Provider Business Practice Location Address
First Line	:	489 DEWDROP CIR APT C
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45240-3799
Country	:	US
Telephone Number	:	513-975-9216
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LAVAR DEON MACK
Credential	:	OT
Telephone Number	:	513-975-9216

Provider Enumeration Date	:	04/18/2023
Last Update Date	:	08/08/2023

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Directions to “ST VOLTAIRE INC ” Practice Location

Language	Start Address	Practice Location

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