Healthcare Provider Details

I. General information

NPI: 1376531343
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

107 N MEDINA ST
LOCKHART TX
78644-1919
US

IV. Provider business mailing address

107 N MEDINA ST
LOCKHART TX
78644-1919
US

V. Phone/Fax

Practice location:
  • Phone: 512-398-5213
  • Fax: 512-376-6880
Mailing address:
  • Phone: 512-398-5213
  • Fax: 512-376-6880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number115093
License Number StateTX

VIII. Authorized Official

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