MEDICARE: LOVELY LAYED WIG SHOP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1790403350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOVELY LAYED WIG SHOP LLC

Provider Business Mailing Address
First Line	:	7565 S HOYNE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60620-5736
Country	:	US
Telephone Number	:	773-603-8535
Fax Number	:

Provider Business Practice Location Address
First Line	:	4007 167TH ST
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-2022
Country	:	US
Telephone Number	:	708-551-5579
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DERICKA COOPER
Credential	:
Telephone Number	:	773-603-8535

Provider Enumeration Date	:	08/19/2022
Last Update Date	:	08/19/2022

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