MEDICARE: DIVERSICARE ESTATES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	114048	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	67-5028	OTHER	TX	MEDICARE SNF

General Provider Information

NPI Number	:	1053511998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSICARE ESTATES LLC

Provider Business Mailing Address
First Line	:	201 SYCAMORE SCHOOL RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-5009
Country	:	US
Telephone Number	:	817-293-7610
Fax Number	:	817-293-5766

Provider Business Practice Location Address
First Line	:	201 SYCAMORE SCHOOL RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-5009
Country	:	US
Telephone Number	:	817-293-7610
Fax Number	:	817-293-5766

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	KELLY J GILL
Credential	:
Telephone Number	:	615-771-7575

Provider Enumeration Date	:	07/19/2007
Last Update Date	:	08/04/2012

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Directions to “DIVERSICARE ESTATES LLC ” Practice Location

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