Provider Demographics
NPI:1447860150
Name:SHADAE RENEE MEDICAL WIGS
Entity type:Organization
Organization Name:SHADAE RENEE MEDICAL WIGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHADAE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-362-6469
Mailing Address - Street 1:10719 ALPHARETTA HWY # 1792
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2432
Mailing Address - Country:US
Mailing Address - Phone:678-362-6469
Mailing Address - Fax:678-325-2731
Practice Address - Street 1:10719 ALPHARETTA HWY # 1792
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2432
Practice Address - Country:US
Practice Address - Phone:678-362-6469
Practice Address - Fax:678-325-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier