Basic Information
| Provider Information | |||||||||
| NPI: | 1831197714 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGENCY CARE OF BLACK MOUNTAIN, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MOUNTAIN RIDGE HEALTH & REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1667 | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286031667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283248898 | ||||||||
| FaxNumber: | 8283229598 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 OLD US HWY 70 E | ||||||||
| Address2: | |||||||||
| City: | BLACK MOUNTAIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287119488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286699991 | ||||||||
| FaxNumber: | 8286699939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 04/22/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOMACK | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8283815360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | NH0235 | NC | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3435048 | 05 | NC | MEDICAID | 922973 | 01 | NC | STATE FACILITY ID | OTHER | NH0235 | 01 | NC | NURSING FACILITY LICENSE NUMBER | OTHER |