Healthcare Provider Details

I. General information

NPI: 1003813569
Provider Name (Legal Business Name): REGENCY TERRACE SOUTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 08/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9449 W FOREST HOME AVE
HALES CORNERS WI
53130-1611
US

IV. Provider business mailing address

9449 W FOREST HOME AVE
HALES CORNERS WI
53130-1611
US

V. Phone/Fax

Practice location:
  • Phone: 414-529-6888
  • Fax: 414-529-1271
Mailing address:
  • Phone: 414-529-6888
  • Fax: 414-529-1271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number3172
License Number StateWI

VIII. Authorized Official

Name: MRS. CYNTHIA BERG
Title or Position: ADMINISTRATOR
Credential:
Phone: 414-529-6888