Provider Demographics
NPI:1922851435
Name:MEMORY LANE LLC
Entity Type:Organization
Organization Name:MEMORY LANE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WOMBOLT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-445-3639
Mailing Address - Street 1:1642 LISA AVE
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-3054
Mailing Address - Country:US
Mailing Address - Phone:760-445-3639
Mailing Address - Fax:
Practice Address - Street 1:1642 LISA AVE
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-3054
Practice Address - Country:US
Practice Address - Phone:760-445-3639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health