Provider Demographics
NPI:1154864213
Name:CARRESHA GOODLOW
Entity Type:Organization
Organization Name:CARRESHA GOODLOW
Other - Org Name:CHARMAINE CAIN HAIR REPLACEMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:
Authorized Official - First Name:CARRESHA
Authorized Official - Middle Name:CHARMAINE
Authorized Official - Last Name:GOODLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-444-2577
Mailing Address - Street 1:PO BOX 6561
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53206-0561
Mailing Address - Country:US
Mailing Address - Phone:731-444-2577
Mailing Address - Fax:
Practice Address - Street 1:820 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:MI
Practice Address - Zip Code:49870-1250
Practice Address - Country:US
Practice Address - Phone:731-444-2577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2701437960335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier