Basic Information
| Provider Information | |||||||||
| NPI: | 1730326828 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGENCY HOSPICE OF NORTHWEST FLORIDA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4060 | ||||||||
| Address2: | |||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281174060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046642876 | ||||||||
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| Practice Location | |||||||||
| Address1: | 50 BEVERLY PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325052814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504782695 | ||||||||
| FaxNumber: | 8504789481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2009 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | COMBS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF LICENSURE | ||||||||
| AuthorizedOfficialTelephone: | 9138142013 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGENCY HOSPICE OF NORTHWEST FLORIDA, INC. | ||||||||
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| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 50370972 | FL | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 001636100 | 05 | FL | MEDICAID |