=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104702687
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIKEY'S MEMORY HCBS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2025
-----------------------------------------------------
Last Update Date | 10/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18308 COMMISSION RD STE A
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39560-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-343-6734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18308 COMMISSION RD STE A
-----------------------------------------------------
City | LONG BEACH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39560-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 228-255-5755
-----------------------------------------------------
Fax | 228-678-2348
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/CEO
-----------------------------------------------------
Name | WILLIAM DODSON
-----------------------------------------------------
Credential | CNA, CCMA
-----------------------------------------------------
Telephone | 228-255-5755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------