Provider Demographics
NPI:1861917171
Name:MEMORY LANE COTTAGE AT OVIEDO, LLC
Entity type:Organization
Organization Name:MEMORY LANE COTTAGE AT OVIEDO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:IRISH
Authorized Official - Suffix:
Authorized Official - Credentials:CORE
Authorized Official - Phone:813-428-3350
Mailing Address - Street 1:999 PONCE DE LEON BLVD STE 950
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-3047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 OVIEDO BLVD
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-3508
Practice Address - Country:US
Practice Address - Phone:407-366-2770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-08
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility