MEDICARE: DIVERSICARE HIGHLANDS, 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

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	:	1568719045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSICARE HIGHLANDS, LLC

Provider Business Mailing Address
First Line	:	1705 STEVENS AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-1044
Country	:	US
Telephone Number	:	502-451-9330
Fax Number	:	615-620-7875

Provider Business Practice Location Address
First Line	:	1705 STEVENS AVE
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40205-1044
Country	:	US
Telephone Number	:	502-451-9330
Fax Number	:	615-620-7875

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

Provider Enumeration Date	:	08/14/2012
Last Update Date	:	06/01/2015

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