Healthcare Provider Details

I. General information

NPI: 1679306773
Provider Name (Legal Business Name): MEMORY LANE SENIOR CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2024
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10255 COMMERCE DR STE 114
CARMEL IN
46032-7429
US

IV. Provider business mailing address

10255 COMMERCE DR STE 114
CARMEL IN
46032-7429
US

V. Phone/Fax

Practice location:
  • Phone: 317-296-3852
  • Fax:
Mailing address:
  • Phone: 317-296-3852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ADMINISTRATIVE TEAM
Title or Position: ADMINISTRATIVE TEAM
Credential:
Phone: 317-296-3852