Organization
LOVELY LAYED WIG SHOP LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DERICKA COOPER (OWNER)
(773) 603-8535
Entity
Organization
Contact information
Practice address
4007 167TH ST, COUNTRY CLUB HILLS, IL 60478-2022
(708) 551-5579
Mailing address
7565 S HOYNE AVE, CHICAGO, IL 60620-5736
(773) 603-8535
Taxonomy
Speciality
Code
Description
License number
State
335E00000X
Prosthetic/Orthotic Supplier
Primary
—
—
Other
Enumeration date
08/19/2022
Last updated
08/19/2022
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