Provider Demographics
NPI:1326708678
Name:A FAMILY HEIRLOOM LLC
Entity Type:Organization
Organization Name:A FAMILY HEIRLOOM LLC
Other - Org Name:FAVORABLE ILLUSIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CRANIAL PROSTHESIS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TA'NESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:AUSTIN-LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-607-1674
Mailing Address - Street 1:6080 PREAKNESS STAKES LN
Mailing Address - Street 2:
Mailing Address - City:POWHATAN
Mailing Address - State:VA
Mailing Address - Zip Code:23139-7091
Mailing Address - Country:US
Mailing Address - Phone:434-607-1674
Mailing Address - Fax:
Practice Address - Street 1:15911 N JAMES MADISON HWY
Practice Address - Street 2:
Practice Address - City:DILLWYN
Practice Address - State:VA
Practice Address - Zip Code:23936-3507
Practice Address - Country:US
Practice Address - Phone:434-607-1674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-28
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier