Provider Demographics
NPI:1770571408
Name:DIVERSICARE LEASING LP
Entity type:Organization
Organization Name:DIVERSICARE LEASING LP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER AND SECRETA
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 1:700 HUTCHINS AVE
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-1876
Mailing Address - Country:US
Mailing Address - Phone:256-543-7101
Mailing Address - Fax:256-543-2367
Practice Address - Street 1:700 HUTCHINS AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-1876
Practice Address - Country:US
Practice Address - Phone:256-543-7101
Practice Address - Fax:256-543-2367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALN2806314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL47-56200SMedicaid
AL01-5223Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER