Healthcare Provider Details

I. General information

NPI: 1477008464
Provider Name (Legal Business Name): DIVERSICARE OF CARTHAGE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2016
Last Update Date: 01/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E FRANKLIN ST
CARTHAGE MS
39051-3603
US

IV. Provider business mailing address

1101 E FRANKLIN ST
CARTHAGE MS
39051-3603
US

V. Phone/Fax

Practice location:
  • Phone: 601-267-4551
  • Fax: 615-620-7875
Mailing address:
  • Phone: 601-267-4551
  • Fax: 615-620-7875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number378
License Number StateMS

VIII. Authorized Official

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