Healthcare Provider Details

I. General information

NPI: 1831644822
Provider Name (Legal Business Name): DIVERSICARE OF BROOKHAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2016
Last Update Date: 04/07/2023
Certification Date: 04/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

519 BROOKMAN DR
BROOKHAVEN MS
39601-2326
US

IV. Provider business mailing address

1621 GALLERIA BLVD
BRENTWOOD TN
37027-2926
US

V. Phone/Fax

Practice location:
  • Phone: 601-833-2881
  • Fax: 601-833-2360
Mailing address:
  • Phone: 615-550-9453
  • Fax: 615-915-6935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number377
License Number StateMS

VIII. Authorized Official

Name: MATTHEW J WEISHAAR
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 615-550-9459