MEDICARE: REGENCY PSYCHIATRIC SERVICES 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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

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	:	1902540974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REGENCY PSYCHIATRIC SERVICES LLC

Provider Business Mailing Address
First Line	:	1116 W PARKER RD STE 308A
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75075-2273
Country	:	US
Telephone Number	:	469-490-1505
Fax Number	:	469-490-1516

Provider Business Practice Location Address
First Line	:	5121 BLUE ROSE ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-2678
Country	:	US
Telephone Number	:	469-490-1505
Fax Number	:	469-490-1516

Authorized Official
Title or Position	:	OWNER
Name	:	NELSON KWOWI
Credential	:
Telephone Number	:	469-490-1505

Provider Enumeration Date	:	04/25/2022
Last Update Date	:	11/08/2023

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