Provider Demographics
NPI:1366997678
Name:MEMORY LANE OF DEXTER, LLC
Entity type:Organization
Organization Name:MEMORY LANE OF DEXTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:P
Authorized Official - Last Name:SELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-614-7472
Mailing Address - Street 1:415 S CATALPA ST
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-2017
Mailing Address - Country:US
Mailing Address - Phone:573-624-7491
Mailing Address - Fax:573-624-2061
Practice Address - Street 1:415 S CATALPA ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-2017
Practice Address - Country:US
Practice Address - Phone:573-624-7491
Practice Address - Fax:573-624-2061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-17
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101456309Medicaid
CA265382Medicare Oscar/Certification