Provider Demographics
NPI:1740664887
Name:MEMORY LANE COTTAGE AT TAMPA PALMS, LLC
Entity type:Organization
Organization Name:MEMORY LANE COTTAGE AT TAMPA PALMS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:IRISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-632-1270
Mailing Address - Street 1:5175 CYPRESS PRESERVE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-3674
Mailing Address - Country:US
Mailing Address - Phone:813-632-1270
Mailing Address - Fax:813-632-1272
Practice Address - Street 1:5175 CYPRESS PRESERVE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3674
Practice Address - Country:US
Practice Address - Phone:813-632-1270
Practice Address - Fax:813-632-1272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-18
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility