Healthcare Provider Details

I. General information

NPI: 1184024424
Provider Name (Legal Business Name): DIVERSICARE OF GREENVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2014
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 GREENE DR
GREENVILLE KY
42345-1409
US

IV. Provider business mailing address

521 GREENE DR
GREENVILLE KY
42345-1409
US

V. Phone/Fax

Practice location:
  • Phone: 270-338-1523
  • Fax: 615-620-7875
Mailing address:
  • Phone: 270-338-1523
  • Fax: 615-620-7875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

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