Provider Demographics
NPI:1104954296
Name:REGENCY SENIOR LIVING ALP
Entity type:Organization
Organization Name:REGENCY SENIOR LIVING ALP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-334-3838
Mailing Address - Street 1:3400 BRUSH HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1712
Mailing Address - Country:US
Mailing Address - Phone:516-334-3838
Mailing Address - Fax:516-334-3866
Practice Address - Street 1:3400 BRUSH HOLLOW RD
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-1712
Practice Address - Country:US
Practice Address - Phone:516-334-3838
Practice Address - Fax:516-334-3866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400-F-295310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02228980Medicaid