Provider Demographics
NPI:1831504521
Name:DIVERSICARE OF ST. JOSEPH, LLC
Entity type:Organization
Organization Name:DIVERSICARE OF ST. JOSEPH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO AND 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 1:3002 N 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64505-1872
Mailing Address - Country:US
Mailing Address - Phone:816-364-4200
Mailing Address - Fax:816-364-4283
Practice Address - Street 1:3002 N 18TH ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64505-1872
Practice Address - Country:US
Practice Address - Phone:816-364-4200
Practice Address - Fax:816-364-4283
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-22
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO042463314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1831504521Medicaid
MO265754Medicare Oscar/Certification