Healthcare Provider Details

I. General information

NPI: 1720076771
Provider Name (Legal Business Name): DIVERSICARE LEASING CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RTE 32 E HOWARD CREEK RD
SANDY HOOK KY
41171
US

IV. Provider business mailing address

PO BOX 694 RTE 32 E HOWARD CREEK RD
SANDY HOOK KY
41171-0694
US

V. Phone/Fax

Practice location:
  • Phone: 606-738-9400
  • Fax: 606-738-9410
Mailing address:
  • Phone: 606-738-9400
  • Fax: 606-738-9410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number100690
License Number StateKY

VIII. Authorized Official

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