=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598149411
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORY LANE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2015
-----------------------------------------------------
Last Update Date | 07/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1012 FAYETTEVILLE RD
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-3471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-474-7223
-----------------------------------------------------
Fax | 479-474-3444
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1012 FAYETTEVILLE RD
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-3471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-474-7223
-----------------------------------------------------
Fax | 479-474-3444
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DEBRA JEAN JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 479-474-7223
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number | 101
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 101
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------