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General NPI Number Information
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NPI Number | 1194690800
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Entity Type | Organization
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Legal Business Name | MEMORY LANE LLC
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Dates
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Enumeration Date | 10/10/2025
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Last Update Date | 10/10/2025
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Provider Practice Location Address
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Address Line | 1642 LISA AVE
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City | VISTA
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State | CA
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Zip | 92084-3054
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Country | US
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Telephone | 760-536-3139
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Fax | 760-806-3582
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Provider Business Mailing Address
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Address Line | 1642 LISA AVE
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City | VISTA
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State | CA
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Zip | 92084-3054
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Country | US
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Telephone | 760-445-3639
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Fax | 760-806-3582
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Authorized Official
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Title or Position | OWNER
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Name | AMY MICHELLE WOMBOLT
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Credential | CDP
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Telephone | 760-445-3639
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 372600000X
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Taxonomy Name | Adult Companion
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3747P1801X
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Taxonomy Name | Personal Care Attendant
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License Number |
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License Number State |
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