Provider Demographics
NPI:1154779635
Name:REGENCY SENIOR CLUB
Entity type:Organization
Organization Name:REGENCY SENIOR CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:WOZNIAK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:520-488-9790
Mailing Address - Street 1:5472 W KARA NICOLE CT
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-8478
Mailing Address - Country:US
Mailing Address - Phone:520-488-9790
Mailing Address - Fax:520-579-9954
Practice Address - Street 1:2972 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-2813
Practice Address - Country:US
Practice Address - Phone:520-488-9790
Practice Address - Fax:520-579-9954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ845737Medicaid
AZ845737Medicaid