Provider Demographics
NPI:1538157649
Name:DIVERSICARE LEASING LP
Entity type:Organization
Organization Name:DIVERSICARE LEASING LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEISHAAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-550-9459
Mailing Address - Street 1:200 MAYFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-3019
Mailing Address - Country:US
Mailing Address - Phone:615-355-0350
Mailing Address - Fax:615-355-5549
Practice Address - Street 1:200 MAYFIELD DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-3019
Practice Address - Country:US
Practice Address - Phone:615-355-0350
Practice Address - Fax:615-355-5549
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DLC GP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-12
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000218314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN744-0450Medicaid
TN744-0450Medicaid