Provider Demographics
NPI:1184720005
Name:PARK REGENCY CARE LLC
Entity type:Organization
Organization Name:PARK REGENCY CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MORTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-577-3880
Mailing Address - Street 1:3050 SATURN STREET
Mailing Address - Street 2:SUITE #201
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-6278
Mailing Address - Country:US
Mailing Address - Phone:714-577-3880
Mailing Address - Fax:714-577-3895
Practice Address - Street 1:1770 W LA HABRA BLVD
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631
Practice Address - Country:US
Practice Address - Phone:714-773-0750
Practice Address - Fax:562-697-8478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC55536GMedicaid
CALTC55536GMedicaid