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General NPI Number Information
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NPI Number | 1740407493
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Entity Type | Organization
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Legal Business Name | PEACHTREE LANE AT MENA, LLC
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Dates
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Enumeration Date | 04/20/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1803 CORDIE DR
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City | MENA
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State | AR
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Zip | 71953-9340
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Country | US
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Telephone | 479-394-2600
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Fax | 479-394-2608
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Provider Business Mailing Address
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Address Line | 1422 FRESNO ST
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City | FORT SMITH
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State | AR
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Zip | 72901-7065
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Country | US
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Telephone | 479-783-0718
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Fax | 479-783-8564
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Authorized Official
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Title or Position | MANAGING MEMBER OWNER
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Name | ANNETTE LANDRUM
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Credential |
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Telephone | 479-783-0718
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 008
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License Number State | AR
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