Provider Demographics
NPI:1598149411
Name:MEMORY LANE, INC.
Entity Type:Organization
Organization Name:MEMORY LANE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-474-7223
Mailing Address - Street 1:1012 FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-3471
Mailing Address - Country:US
Mailing Address - Phone:479-474-7223
Mailing Address - Fax:479-474-3444
Practice Address - Street 1:1012 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-3471
Practice Address - Country:US
Practice Address - Phone:479-474-7223
Practice Address - Fax:479-474-3444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR101310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR101OtherASSISTED LIVING LEVEL II