Basic Information
| Provider Information | |||||||||
| NPI: | 1871589093 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGENCY CARE OF BLOUNTSTOWN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BLOUNTSTOWN HEALTH & REHABILITATION CENTER | ||||||||
| 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: | 16690 SW CHIPOLA RD | ||||||||
| Address2: | |||||||||
| City: | BLOUNTSTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324241953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506744311 | ||||||||
| FaxNumber: | 8508743798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 04/22/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOMACK | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8283815360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | SNF1652096 | FL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | SNF1652096 | 01 | FL | STATE SNF LICENSE NUMBER | OTHER | 002298700 | 05 | FL | MEDICAID | 35960874 | 01 | FL | STATE FACILITY MDS ID NUM | OTHER |