Provider Demographics
NPI:1063940732
Name:MEMORY LANE ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:MEMORY LANE ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DSN/ ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADA
Authorized Official - Middle Name:
Authorized Official - Last Name:FISCU
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:832-627-6918
Mailing Address - Street 1:32802 WRIGHT RD
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:TX
Mailing Address - Zip Code:77355-8456
Mailing Address - Country:US
Mailing Address - Phone:281-259-9657
Mailing Address - Fax:281-259-2936
Practice Address - Street 1:32802 WRIGHT RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77355-8456
Practice Address - Country:US
Practice Address - Phone:281-259-9657
Practice Address - Fax:281-259-2936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility