Provider Demographics
NPI:1104702687
Name:MIKEY'S MEMORY LLC
Entity type:Organization
Organization Name:MIKEY'S MEMORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DODSON
Authorized Official - Suffix:
Authorized Official - Credentials:CNA, CCMA
Authorized Official - Phone:228-343-6734
Mailing Address - Street 1:18308 COMMISSION RD STE A
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:MS
Mailing Address - Zip Code:39560-2402
Mailing Address - Country:US
Mailing Address - Phone:228-343-6734
Mailing Address - Fax:
Practice Address - Street 1:18308 COMMISSION RD STE A
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:MS
Practice Address - Zip Code:39560-2402
Practice Address - Country:US
Practice Address - Phone:228-343-6734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-12
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No385H00000XRespite Care FacilityRespite Care
No251E00000XAgenciesHome Health
No251G00000XAgenciesHospice Care, Community Based
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No376K00000XNursing Service Related ProvidersNurse's Aide
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child