MEDICARE: DIVERSICARE TREEMONT 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	120029	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	45-5823	OTHER	TX	MEDICARE SNF

General Provider Information

NPI Number	:	1235338732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSICARE TREEMONT LLC

Provider Business Mailing Address
First Line	:	5550 HARVEST HILL RD
Second Line	:	SUITE 500
City	:	DALLAS
State	:	TX
Zip	:	75230-1624
Country	:	US
Telephone Number	:	972-661-1862
Fax Number	:	972-980-6731

Provider Business Practice Location Address
First Line	:	5550 HARVEST HILL RD
Second Line	:	SUITE 500
City	:	DALLAS
State	:	TX
Zip	:	75230-1624
Country	:	US
Telephone Number	:	972-661-1862
Fax Number	:	972-980-6731

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

Provider Enumeration Date	:	07/13/2007
Last Update Date	:	02/18/2015

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