Healthcare Provider Details

I. General information

NPI: 1225960453
Provider Name (Legal Business Name): LAVEA LACE CUSTOM WIGS AND HAIRPIECES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1382 MACKINAW AVE
CALUMET CITY IL
60409-5928
US

IV. Provider business mailing address

18141 DIXIE HWY STE 202
HOMEWOOD IL
60430-2243
US

V. Phone/Fax

Practice location:
  • Phone: 708-916-5093
  • Fax:
Mailing address:
  • Phone: 708-916-5093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: HAKEEM GAYDEN
Title or Position: OWNER
Credential:
Phone: 708-916-5093