MEDICARE: CCRC - REGENCY OAKS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164836425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCRC - REGENCY OAKS, LLC

Provider Business Mailing Address
First Line	:	1920 MAIN ST STE 1200
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-7230
Country	:	US
Telephone Number	:	949-407-0700
Fax Number	:

Provider Business Practice Location Address
First Line	:	2770 REGENCY OAKS BLVD
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33759-1509
Country	:	US
Telephone Number	:	727-791-7743
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	KYLE BOLDEN
Credential	:
Telephone Number	:	727-791-3381

Provider Enumeration Date	:	06/16/2014
Last Update Date	:	01/19/2026

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