Provider Demographics
NPI:1063479160
Name:REGAL HEALTH AND REHAB
Entity type:Organization
Organization Name:REGAL HEALTH AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:E
Authorized Official - Last Name:VAN DUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-636-7000
Mailing Address - Street 1:9525 MAYFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2817
Mailing Address - Country:US
Mailing Address - Phone:708-636-7000
Mailing Address - Fax:708-422-3520
Practice Address - Street 1:9525 MAYFIELD AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2817
Practice Address - Country:US
Practice Address - Phone:708-636-7000
Practice Address - Fax:708-422-3520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0038091314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0038091OtherSTATE LICENSE
IL=========0002Medicaid
IL145942Medicare ID - Type Unspecified