Provider Demographics
NPI:1770962730
Name:DIVERSICARE OF GRAND JUNCTION I, LLC
Entity type:Organization
Organization Name:DIVERSICARE OF GRAND JUNCTION I, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:2501 LITTLE BOOKCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-8802
Mailing Address - Country:US
Mailing Address - Phone:970-245-1211
Mailing Address - Fax:615-620-7875
Practice Address - Street 1:2501 LITTLE BOOKCLIFF DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-8802
Practice Address - Country:US
Practice Address - Phone:970-245-1211
Practice Address - Fax:615-620-7875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-23
Last Update Date:2015-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility