MEDICARE: MEMORY LANE ASSISTED LIVING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	253Z00000X	In Home Supportive Care Agency
2	385H00000X	Respite Care
3	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1114722097
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEMORY LANE ASSISTED LIVING

Provider Business Mailing Address
First Line	:	15117 EMORY CIR
Second Line	:
City	:	APPLE VALLEY
State	:	MN
Zip	:	55124-1808
Country	:	US
Telephone Number	:	612-298-0555
Fax Number	:

Provider Business Practice Location Address
First Line	:	15117 EMORY CIR
Second Line	:
City	:	APPLE VALLEY
State	:	MN
Zip	:	55124-1808
Country	:	US
Telephone Number	:	612-298-0555
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	ABDIASIS HIRSI
Credential	:
Telephone Number	:	612-298-0555

Provider Enumeration Date	:	02/15/2025
Last Update Date	:	02/15/2025

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Directions to “MEMORY LANE ASSISTED LIVING ” Practice Location

Language	Start Address	Practice Location

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