Healthcare Provider Details

I. General information

NPI: 1174511398
Provider Name (Legal Business Name): DIVERSICARE LEASING CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 11/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12800 PRINCELAND DR
ASHLAND KY
41102-9681
US

IV. Provider business mailing address

12800 PRINCELAND DR
ASHLAND KY
41102-9681
US

V. Phone/Fax

Practice location:
  • Phone: 606-928-2963
  • Fax: 606-928-3879
Mailing address:
  • Phone: 606-928-2963
  • Fax: 606-928-3879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100689
License Number StateKY

VIII. Authorized Official

Name: RAYMOND L. TYLER JR.
Title or Position: EXECUTIVE VICE PRESIDENT AND COO
Credential:
Phone: 615-771-7575