Healthcare Provider Details

I. General information

NPI: 1053275792
Provider Name (Legal Business Name): DOMANAIRE DAVENPORT-BLEDSOE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 W BARTGES ST
AKRON OH
44311-1029
US

IV. Provider business mailing address

58 W BARTGES ST
AKRON OH
44311-1029
US

V. Phone/Fax

Practice location:
  • Phone: 330-564-5311
  • Fax:
Mailing address:
  • Phone: 330-564-5311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: