Provider Demographics
NPI:1154031615
Name:PAISLEY-GREEN, RENEE MIKEASHA (HAIR REPLACEMENT SPC)
Entity type:Individual
Prefix:
First Name:RENEE
Middle Name:MIKEASHA
Last Name:PAISLEY-GREEN
Suffix:
Gender:F
Credentials:HAIR REPLACEMENT SPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2852 DEANS BRIDGE RD STE C
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-2767
Mailing Address - Country:US
Mailing Address - Phone:954-305-4061
Mailing Address - Fax:
Practice Address - Street 1:2852 DEANS BRIDGE RD STE C
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-2767
Practice Address - Country:US
Practice Address - Phone:954-305-4061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-24
Last Update Date:2022-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACO134520332B00000X, 335E00000X, 174400000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier