Provider Demographics
NPI:1164836425
Name:CCRC - REGENCY OAKS, LLC
Entity type:Organization
Organization Name:CCRC - REGENCY OAKS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-791-3381
Mailing Address - Street 1:1920 MAIN ST STE 1200
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-7230
Mailing Address - Country:US
Mailing Address - Phone:949-407-0700
Mailing Address - Fax:
Practice Address - Street 1:2770 REGENCY OAKS BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-1509
Practice Address - Country:US
Practice Address - Phone:727-791-7743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
105744Medicare Oscar/Certification