Provider Demographics
NPI:1720062441
Name:REGENCY VILLAGE CARE CENTER, LTD
Entity Type:Organization
Organization Name:REGENCY VILLAGE CARE CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-340-7155
Mailing Address - Street 1:845 PROTON RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4203
Mailing Address - Country:US
Mailing Address - Phone:210-582-3716
Mailing Address - Fax:210-582-3816
Practice Address - Street 1:6500 BRUSH COUNTRY RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1403
Practice Address - Country:US
Practice Address - Phone:512-892-5774
Practice Address - Fax:512-892-5334
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHICHESTER HOLDINGS, LLC: GENERAL PARTNER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-06
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113061313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000526303Medicaid
TX021856201OtherTEXAS PROVIDER IDENTIFIER
675118Medicare ID - Type UnspecifiedMUTUAL OF OMAHA