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

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Laboratory Demographics

CLIA Number: 04D2193755

Facility Name: VAN BUREN LEGACY LLC (MEMORY LANE)

Facility Address:
1012 FAYETTEVILLE ROAD
VAN BUREN, AR
ZIP 72956
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Facility Phone Number: 479 474-7233

Facility Type: Assisted Living Facility

Certificate Type: Waiver

NPI Number: 1407320658

Taxonomy: 310400000X - Assisted Living Facility
A facility providing supportive services to individuals who can function independently in most areas of activity, but need assistance and/or monitoring to assure safety and well being.

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
CertificateType	4
CertificateEffectiveDate	9/24/2022
CertificateExpirationDate	9/23/2024
FacilityType	Waiver

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This page was last updated on: 4/23/2024