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General NPI Number Information
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NPI Number | 1407320658
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Entity Type | Organization
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Legal Business Name | VAN BUREN LEGACY LLC
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Dates
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Enumeration Date | 01/21/2019
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Last Update Date | 01/21/2019
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Provider Practice Location Address
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Address Line | 1012 FAYETTEVILLE RD
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City | VAN BUREN
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State | AR
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Zip | 72956-3471
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Country | US
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Telephone | 479-474-7233
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Fax | 479-474-3444
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Provider Business Mailing Address
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Address Line | 1012 FAYETTEVILLE RD
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City | VAN BUREN
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State | AR
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Zip | 72956-3471
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Country | US
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Telephone | 479-474-7233
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Fax | 479-474-3444
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. TIFFANY PERRYMAN
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Credential |
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Telephone | 479-474-7233
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311500000X
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Taxonomy Name | Alzheimer Center (Dementia Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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