Provider Demographics
NPI:1356491369
Name:REGENCY ON THE LAKE-FORT GRATIOT, LLC
Entity Type:Organization
Organization Name:REGENCY ON THE LAKE-FORT GRATIOT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:ASHRAF
Authorized Official - Last Name:QAZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-386-0300
Mailing Address - Street 1:5669 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-2817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5669 LAKESHORE RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-2817
Practice Address - Country:US
Practice Address - Phone:810-385-7260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIENA HEALTHCARE MANAGEMENT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-11
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI09594OtherBCBSM PROVIDER CODE
MI4988052Medicaid
MI4988052Medicaid