Provider Demographics
NPI:1528126232
Name:REGENCY HOUSE OF WALLINGFORD, INC.
Entity type:Organization
Organization Name:REGENCY HOUSE OF WALLINGFORD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF COMPLIANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-265-1661
Mailing Address - Street 1:181 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3947
Mailing Address - Country:US
Mailing Address - Phone:203-265-1661
Mailing Address - Fax:203-265-7842
Practice Address - Street 1:181 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3947
Practice Address - Country:US
Practice Address - Phone:203-265-1661
Practice Address - Fax:203-265-7842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2072C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000009084Medicaid
CT075261Medicare ID - Type Unspecified