Provider Demographics
NPI:1235986191
Name:GREEN, DESARAE M (CRANIAL PROSTHESIS)
Entity type:Individual
Prefix:
First Name:DESARAE
Middle Name:M
Last Name:GREEN
Suffix:
Gender:F
Credentials:CRANIAL PROSTHESIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 S TAYLOR RD # 203
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2103
Mailing Address - Country:US
Mailing Address - Phone:440-431-9108
Mailing Address - Fax:
Practice Address - Street 1:1917 S TAYLOR RD # 203
Practice Address - Street 2:
Practice Address - City:CLEVELAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44118-2103
Practice Address - Country:US
Practice Address - Phone:440-431-9108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier