Healthcare Provider Details

I. General information

NPI: 1407320658
Provider Name (Legal Business Name): VAN BUREN LEGACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2019
Last Update Date: 01/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 FAYETTEVILLE RD
VAN BUREN AR
72956-3471
US

IV. Provider business mailing address

1012 FAYETTEVILLE RD
VAN BUREN AR
72956-3471
US

V. Phone/Fax

Practice location:
  • Phone: 479-474-7233
  • Fax: 479-474-3444
Mailing address:
  • Phone: 479-474-7233
  • Fax: 479-474-3444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. TIFFANY PERRYMAN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 479-474-7233