MEDICARE: REGAL SENIOR LIVING CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	385H00000X	Respite Care	197607719	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	197607719	OTHER	CA	COMMUNITY CARE LICENSING DIVISION

General Provider Information

NPI Number	:	1710217369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGAL SENIOR LIVING CORPORATION

Provider Business Mailing Address
First Line	:	1009 S CITRUS ST
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91791-3403
Country	:	US
Telephone Number	:	626-339-5402
Fax Number	:	626-373-2433

Provider Business Practice Location Address
First Line	:	1009 S CITRUS ST
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91791-3403
Country	:	US
Telephone Number	:	626-339-5402
Fax Number	:	626-373-2433

Authorized Official
Title or Position	:	RCFE ADMINISTRATOR
Name	:	MRS. ELLEN VANN JONES
Credential	:
Telephone Number	:	626-705-8021

Provider Enumeration Date	:	01/05/2010
Last Update Date	:	01/05/2010

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