Basic Information
| Provider Information | |||||||||
| NPI: | 1437193729 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGAL PALMS LIMITED PARTNERSHIP | ||||||||
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| OtherOrganizationName: | REGAL PALMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 HAZELTINE BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHASKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553181009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9523618000 | ||||||||
| FaxNumber: | 9523618058 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 LAKE AVE NE | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337716605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274371350 | ||||||||
| FaxNumber: | 7274371365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEICHERT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 9523618000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AL9570 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 06493 | 01 | UNIVERSAL HEALTHCARE | OTHER | 235126 | 01 | AMERIGROUP | OTHER | 681327500 | 05 | FL | MEDICAID |