MEDICARE: DESARAE M GREEN CRANIAL PROSTHESIS

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1235986191
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESARAE M GREEN CRANIAL PROSTHESIS

Provider Business Mailing Address
First Line	:	1917 S TAYLOR RD # 203
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-2103
Country	:	US
Telephone Number	:	440-431-9108
Fax Number	:

Provider Business Practice Location Address
First Line	:	1917 S TAYLOR RD # 203
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44118-2103
Country	:	US
Telephone Number	:	440-431-9108
Fax Number	:

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

Provider Enumeration Date	:	04/30/2024
Last Update Date	:	04/30/2024

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