Provider Demographics
NPI:1538857115
Name:KEAVA'S HAIR CASTLE LLC
Entity type:Organization
Organization Name:KEAVA'S HAIR CASTLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL WIG PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:B
Authorized Official - Last Name:RAWLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-365-2102
Mailing Address - Street 1:3303 AIRLINE BLVD STE 3F
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701-2635
Mailing Address - Country:US
Mailing Address - Phone:804-365-2102
Mailing Address - Fax:
Practice Address - Street 1:3303 AIRLINE BLVD STE 3F
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-2635
Practice Address - Country:US
Practice Address - Phone:804-365-2102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier