Provider Demographics
NPI:1225105273
Name:REGENCY CARE OF CLEMMONS, LLC
Entity Type:Organization
Organization Name:REGENCY CARE OF CLEMMONS, LLC
Other - Org Name:REGENCY CARE OF CLEMMONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:828-381-5360
Mailing Address - Street 1:PO BOX 1667
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28603-1667
Mailing Address - Country:US
Mailing Address - Phone:828-324-8898
Mailing Address - Fax:828-322-9598
Practice Address - Street 1:3905 CLEMMONS ROAD
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8479
Practice Address - Country:US
Practice Address - Phone:336-766-9158
Practice Address - Fax:336-766-8666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0404314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3435131Medicaid
NC923335OtherFACILITY ID NUMBER
NCNH0404OtherSTATE LICENSE
NCNH0404OtherSTATE LICENSE
NC3435131Medicaid