Healthcare Provider Details

I. General information

NPI: 1558769505
Provider Name (Legal Business Name): DIVERSICARE OF GLASGOW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2014
Last Update Date: 06/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 WESTWOOD ST
GLASGOW KY
42141-1030
US

IV. Provider business mailing address

300 WESTWOOD ST
GLASGOW KY
42141-1030
US

V. Phone/Fax

Practice location:
  • Phone: 270-651-9131
  • Fax: 615-620-7875
Mailing address:
  • Phone: 270-651-9131
  • Fax: 615-620-7875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100509
License Number StateKY

VIII. Authorized Official

Name: KELLY J GILL
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 615-771-7575