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
1	314000000X	Skilled Nursing Facility	115093	TX

Other Identifiers

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

General Provider Information

NPI Number	:	1376531343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSICARE LEASING CORP.

Provider Business Mailing Address
First Line	:	107 N MEDINA ST
Second Line	:
City	:	LOCKHART
State	:	TX
Zip	:	78644-1919
Country	:	US
Telephone Number	:	512-398-5213
Fax Number	:	512-376-6880

Provider Business Practice Location Address
First Line	:	107 N MEDINA ST
Second Line	:
City	:	LOCKHART
State	:	TX
Zip	:	78644-1919
Country	:	US
Telephone Number	:	512-398-5213
Fax Number	:	512-376-6880

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

Provider Enumeration Date	:	10/12/2005
Last Update Date	:	08/22/2020

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Directions to “DIVERSICARE LEASING CORP. ” Practice Location

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