Provider Demographics
NPI:1194690800
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:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:WOMBOLT
Authorized Official - Suffix:
Authorized Official - Credentials:CDP
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:760-806-3582
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:760-536-3139
Practice Address - Fax:760-806-3582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-10
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Multi-Specialty