Healthcare Provider Details

I. General information

NPI: 1740407493
Provider Name (Legal Business Name): PEACHTREE LANE AT MENA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1803 CORDIE DR
MENA AR
71953-9340
US

IV. Provider business mailing address

1422 FRESNO ST
FORT SMITH AR
72901-7065
US

V. Phone/Fax

Practice location:
  • Phone: 479-394-2600
  • Fax: 479-394-2608
Mailing address:
  • Phone: 479-783-0718
  • Fax: 479-783-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number008
License Number StateAR

VIII. Authorized Official

Name: ANNETTE LANDRUM
Title or Position: MANAGING MEMBER OWNER
Credential:
Phone: 479-783-0718