Provider Demographics
NPI:1447453022
Name:REGENCY PROVIDER SERVICES INC
Entity type:Organization
Organization Name:REGENCY PROVIDER SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EZIAKU
Authorized Official - Middle Name:JENNIFER
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:469-547-1980
Mailing Address - Street 1:3939 E US HWY 80, SUITE 273
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4662
Mailing Address - Country:US
Mailing Address - Phone:469-547-1980
Mailing Address - Fax:469-547-1982
Practice Address - Street 1:7308 FOREST BEND DR
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:TX
Practice Address - Zip Code:75002-6817
Practice Address - Country:US
Practice Address - Phone:972-922-4510
Practice Address - Fax:469-547-1982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-09
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX011327251E00000X
251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX747133Medicare PIN