Basic Information
| Provider Information | |||||||||
| NPI: | 1427057918 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENCY HERITAGE NURSING & REHABILITATION CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 643 CROSS ST | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087014610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327309280 | ||||||||
| FaxNumber: | 7327309278 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 DEMOTT LANE | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088732762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328732000 | ||||||||
| FaxNumber: | 7328732112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 09/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | STEFANSKY | ||||||||
| AuthorizedOfficialFirstName: | AARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 7327309280 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 061801 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 18150/4499107 | 05 | NJ | MEDICAID |