Provider Demographics
NPI:1699802835
Name:REGENCY GRANDE NURSING AND REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:REGENCY GRANDE NURSING AND REHABILITATION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:STEFANSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-730-9280
Mailing Address - Street 1:643 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701
Mailing Address - Country:US
Mailing Address - Phone:732-730-9280
Mailing Address - Fax:732-730-8407
Practice Address - Street 1:65 N SUSSEX ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801
Practice Address - Country:US
Practice Address - Phone:973-361-5200
Practice Address - Fax:973-361-0375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ603300313M00000X
NJ061423314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4491807Medicaid
315355Medicare ID - Type Unspecified