Basic Information
| Provider Information | |||||||||
| NPI: | 1699824979 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENCY PARK NURSING AND REHABILITATION CENTER OF JEFFERON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 RAM DR | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501292728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5153864107 | ||||||||
| FaxNumber: | 5153862347 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 RAM DR | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501292728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5153864107 | ||||||||
| FaxNumber: | 5153862347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CARPENTER | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | ALLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5153864107 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | NHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 370034 | IA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0650390 | 05 | IA | MEDICAID |