MEDICARE: MRS. OLGA VISHNEVETSKY OTR L

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	174400000X	Specialist	2000174035	MO

General Provider Information

NPI Number	:	1477759942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. OLGA VISHNEVETSKY OTR L

Provider Business Mailing Address
First Line	:	1320 BARDOT LN
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-5331
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3225 N FLORISSANT AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63107-3521
Country	:	US
Telephone Number	:	314-621-1244
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2007
Last Update Date	:	07/08/2007

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