=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871589093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGENCY CARE OF BLOUNTSTOWN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2005
-----------------------------------------------------
Last Update Date | 04/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16690 SW CHIPOLA RD
-----------------------------------------------------
City | BLOUNTSTOWN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32424-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-674-4311
-----------------------------------------------------
Fax | 850-874-3798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1667
-----------------------------------------------------
City | HICKORY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28603-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-324-8898
-----------------------------------------------------
Fax | 828-322-9598
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MR. STEVEN D WOMACK
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 828-381-5360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | SNF1652096
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------