Healthcare Provider Details

I. General information

NPI: 1144260589
Provider Name (Legal Business Name): REGENCY HOME HEALTHCARE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 05/05/2020
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10467 93RD AVE N
MAPLE GROVE MN
55369-4112
US

IV. Provider business mailing address

10467 93RD AVE N
MAPLE GROVE MN
55369-4112
US

V. Phone/Fax

Practice location:
  • Phone: 651-488-4655
  • Fax: 651-488-4656
Mailing address:
  • Phone: 651-488-4655
  • Fax: 651-488-4656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number329047
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MS. JEAN ANN JOHNSON
Title or Position: ADMINISTRATOR/OWNER
Credential: RN/RRT
Phone: 651-488-4655