Healthcare Provider Details

I. General information

NPI: 1538157649
Provider Name (Legal Business Name): DIVERSICARE LEASING LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MAYFIELD DR
SMYRNA TN
37167-3019
US

IV. Provider business mailing address

200 MAYFIELD DR
SMYRNA TN
37167-3019
US

V. Phone/Fax

Practice location:
  • Phone: 615-355-0350
  • Fax: 615-355-5549
Mailing address:
  • Phone: 615-355-0350
  • Fax: 615-355-5549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0000000218
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier744-0450
Identifier TypeMEDICAID
Identifier StateTN
Identifier Issuer

VIII. Authorized Official

Name: MATTHEW J. WEISHAAR
Title or Position: CFO/SECRETARY
Credential:
Phone: 615-550-9459