Provider Demographics
NPI:1790362424
Name:GREENE, CINNAMON R
Entity Type:Individual
Prefix:
First Name:CINNAMON
Middle Name:R
Last Name:GREENE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 LAFAYETTE RD UNIT 17
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-3706
Mailing Address - Country:US
Mailing Address - Phone:330-952-3554
Mailing Address - Fax:
Practice Address - Street 1:801 E WASHINGTON ST STE 130
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-3327
Practice Address - Country:US
Practice Address - Phone:330-952-3554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-27
Last Update Date:2021-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.025288225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1327081-0001OtherBWC