Provider Demographics
NPI:1013908698
Name:REGENCY TERRACE SOUTH INC
Entity Type:Organization
Organization Name:REGENCY TERRACE SOUTH INC
Other - Org Name:CARE-AGE OF BROOKFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF NURSING
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:BARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:262-821-3939
Mailing Address - Street 1:1755 N BARKER RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-1801
Mailing Address - Country:US
Mailing Address - Phone:262-821-3939
Mailing Address - Fax:262-821-3944
Practice Address - Street 1:1755 N BARKER RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-1801
Practice Address - Country:US
Practice Address - Phone:262-821-3939
Practice Address - Fax:262-821-3944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3121314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20173600Medicaid
WI20173600Medicaid