Healthcare Provider Details

I. General information

NPI: 1184720005
Provider Name (Legal Business Name): PARK REGENCY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1770 W LA HABRA BLVD
LA HABRA CA
90631
US

IV. Provider business mailing address

3050 SATURN STREET SUITE #201
BREA CA
92821-6278
US

V. Phone/Fax

Practice location:
  • Phone: 714-773-0750
  • Fax: 562-697-8478
Mailing address:
  • Phone: 714-577-3880
  • Fax: 714-577-3895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. MARK A MORTENSEN
Title or Position: SR VP FINANCE
Credential:
Phone: 714-577-3880