Healthcare Provider Details

I. General information

NPI: 1033083209
Provider Name (Legal Business Name): MEMORY LANE AT HOME AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 10/05/2025
Certification Date: 10/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

254 COURT AVE # 205
MEMPHIS TN
38103-2361
US

IV. Provider business mailing address

254 COURT AVE # 205
MEMPHIS TN
38103-2361
US

V. Phone/Fax

Practice location:
  • Phone: 901-221-4430
  • Fax: 901-207-8860
Mailing address:
  • Phone: 901-221-4430
  • Fax: 901-207-8860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: TAMARA M CLARK
Title or Position: OWNER
Credential:
Phone: 901-297-6113