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NPI Code Detail

MEDICARE: DIVERSICARE LEASING CORP.

MEDICARE: DIVERSICARE LEASING CORP.
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
1314000000XSkilled Nursing Facility100571KY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1093703308
Entity Type Code : Organization
Provider Name (Legal Business Name) : DIVERSICARE LEASING CORP.
Provider Business Mailing Address
First Line : 250 MCDAVID BLVD
Second Line :
City : GRAYSON
State : KY
Zip : 41143-1603
Country : US
Telephone Number : 606-474-7835
Fax Number : 606-474-8114
Provider Business Practice Location Address
First Line : 250 MCDAVID BLVD
Second Line :
City : GRAYSON
State : KY
Zip : 41143-1603
Country : US
Telephone Number : 606-474-7835
Fax Number : 606-474-8114
Authorized Official
Title or Position : EXECUTIVE VICE PRESIDENT AND COO
Name : RAYMOND L. TYLER JR.
Credential :
Telephone Number : 615-771-7575
Provider Enumeration Date : 10/11/2005
Last Update Date : 08/22/2020

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Directions to “DIVERSICARE LEASING CORP. ” Practice Location

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