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	542	AR

General Provider Information

NPI Number	:	1750379335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSICARE LEASING CORP.

Provider Business Mailing Address
First Line	:	105 RUSSELLVILLE RD
Second Line	:
City	:	MALVERN
State	:	AR
Zip	:	72104-6700
Country	:	US
Telephone Number	:	501-332-5251
Fax Number	:	501-337-9354

Provider Business Practice Location Address
First Line	:	105 RUSSELLVILLE RD
Second Line	:
City	:	MALVERN
State	:	AR
Zip	:	72104-6700
Country	:	US
Telephone Number	:	501-332-5251
Fax Number	:	501-337-9354

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

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

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