Provider Demographics
NPI:1790403350
Name:LOVELY LAYED WIG SHOP LLC
Entity Type:Organization
Organization Name:LOVELY LAYED WIG SHOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DERICKA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-603-8535
Mailing Address - Street 1:7565 S HOYNE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-5736
Mailing Address - Country:US
Mailing Address - Phone:773-603-8535
Mailing Address - Fax:
Practice Address - Street 1:4007 167TH ST
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-2022
Practice Address - Country:US
Practice Address - Phone:708-551-5579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier