=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225974710
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COVENANT CRANIAL MEDICAL WIGS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2026
-----------------------------------------------------
Last Update Date | 04/27/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1021 BOULEVARD
-----------------------------------------------------
City | COLONIAL HGTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-3258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-844-6359
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8307 SCOTT PL
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23227-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-451-8343
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/INSTRUCTOR
-----------------------------------------------------
Name | LASATT NICHELE TILLMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 804-451-8343
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------