Healthcare Provider Details

I. General information

NPI: 1386631182
Provider Name (Legal Business Name): DIVERSICARE LEASING LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4164 HALLS MILL RD
MOBILE AL
36693-5614
US

IV. Provider business mailing address

4164 HALLS MILL RD
MOBILE AL
36693-5614
US

V. Phone/Fax

Practice location:
  • Phone: 251-661-5404
  • Fax: 251-661-5407
Mailing address:
  • Phone: 251-661-5404
  • Fax: 251-661-5407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberN4907
License Number StateAL

VIII. Authorized Official

Name: MATTHEW J. WEISHAAR JR.
Title or Position: CFO/SECRETARY
Credential:
Phone: 615-550-9459