04D2193755 CLIA NUMBER - VAN BUREN LEGACY LLC (MEMORY LANE)

Laboratory Demographics

  • CLIA Code: 04D2193755
  • Facility Name: VAN BUREN LEGACY LLC (MEMORY LANE)
  • Facility Address: 1012 FAYETTEVILLE ROAD
    VAN BUREN, AR
    ZIP 72956
  • Facility Phone: 479 474-7233
  • Facility Type: Assisted Living Facility
  • Facility Type: Waiver
  • Lab Director: LADONNA SYROCK
  • NPI Number: 1407320658
  • Taxonomy: 310400000X - Assisted Living Facility

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CLIA Record

Field Name Field Value
CLIA Number 04D2193755
LAB Type Assisted Living Facility
Facility Name VAN BUREN LEGACY LLC (MEMORY LANE)
Street 1012 FAYETTEVILLE ROAD
City VAN BUREN
State AR
ZIP 72956
Phone 479 474-7233
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 9/24/2024
Certificate Expiration Date 9/23/2026
Facility Type Assisted Living Facility
Lab Director LADONNA SYROCK

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This page was last updated on: 9/29/2025