Basic Information
| Provider Information | |||||||||
| NPI: | 1053557009 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RUTLEDGE-REGENCY OPERATIONS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | REGENCY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 115 W JEFFERSON ST | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617013946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098284361 | ||||||||
| FaxNumber: | 3098295477 | ||||||||
| Practice Location | |||||||||
| Address1: | 2120 W WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627024630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177934880 | ||||||||
| FaxNumber: | 2177934894 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2008 | ||||||||
| LastUpdateDate: | 02/12/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | UNDERWOOD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3098237135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0050138 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.