Healthcare Provider Details

I. General information

NPI: 1891102760
Provider Name (Legal Business Name): DIVERSICARE OF AVON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2014
Last Update Date: 07/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32900 DETROIT RD
AVON OH
44011-2018
US

IV. Provider business mailing address

32900 DETROIT RD
AVON OH
44011-2018
US

V. Phone/Fax

Practice location:
  • Phone: 440-937-6201
  • Fax: 440-937-5955
Mailing address:
  • Phone: 440-937-6201
  • Fax: 440-937-5955

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