Organization
MEMORY LANE, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DEBRA JEAN JOHNSON (EXECUTIVE DIRECTOR)
(479) 474-7223
Entity
Organization
Contact information
Practice address
1012 FAYETTEVILLE RD, VAN BUREN, AR 72956-3471
(479) 474-7223
(479) 474-3444
Mailing address
1012 FAYETTEVILLE RD, VAN BUREN, AR 72956-3471
(479) 474-7223
(479) 474-3444
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
101
AR
311500000X
Alzheimer Center (Dementia Center)
101
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
101
ASSISTED LIVING LEVEL II
AR
Enumeration date
07/10/2015
Last updated
07/10/2015
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