Basic Information
| Provider Information | |||||||||
| NPI: | 1346292638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SLP REGENCY MANOR LLC | ||||||||
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| OtherOrganizationName: | REGENCY MANOR HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1300 S UNIVERSITY DR STE 306 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761075746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174107300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3011 W ADAMS AVE | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 765042873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547331626 | ||||||||
| FaxNumber: | 2547703074 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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| AuthorizedOfficialLastName: | MISTRETTA | ||||||||
| AuthorizedOfficialFirstName: | CASSANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8174107300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004748 | 01 | TX | FACILITY ID NO. | OTHER |