Healthcare Provider Details

I. General information

NPI: 1871589093
Provider Name (Legal Business Name): REGENCY CARE OF BLOUNTSTOWN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16690 SW CHIPOLA RD
BLOUNTSTOWN FL
32424-1953
US

IV. Provider business mailing address

PO BOX 1667
HICKORY NC
28603-1667
US

V. Phone/Fax

Practice location:
  • Phone: 850-674-4311
  • Fax: 850-874-3798
Mailing address:
  • Phone: 828-324-8898
  • Fax: 828-322-9598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1652096
License Number StateFL

VIII. Authorized Official

Name: MR. STEVEN D WOMACK
Title or Position: MANAGING MEMBER
Credential: CPA
Phone: 828-381-5360