Provider Demographics
NPI:1023569738
Name:REGAL LEGACY GROUP LLC
Entity Type:Organization
Organization Name:REGAL LEGACY GROUP LLC
Other - Org Name:MOYER'S ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:L
Authorized Official - Last Name:REID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-587-4603
Mailing Address - Street 1:185 CRUTCHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-8261
Mailing Address - Country:US
Mailing Address - Phone:336-587-4603
Mailing Address - Fax:866-571-9651
Practice Address - Street 1:5767 NC HIGHWAY 135
Practice Address - Street 2:
Practice Address - City:STONEVILLE
Practice Address - State:NC
Practice Address - Zip Code:27048-8477
Practice Address - Country:US
Practice Address - Phone:336-587-4603
Practice Address - Fax:866-571-9651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC=========Medicaid