Basic Information
| Provider Information | |||||||||
| NPI: | 1053511998 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIVERSICARE ESTATES LLC | ||||||||
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| OtherOrganizationName: | ESTATES HEALTHCARE AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 SYCAMORE SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761345009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172937610 | ||||||||
| FaxNumber: | 8172935766 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 SYCAMORE SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761345009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172937610 | ||||||||
| FaxNumber: | 8172935766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 08/04/2012 | ||||||||
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| AuthorizedOfficialLastName: | GILL | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
| AuthorizedOfficialTelephone: | 6157717575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVOCAT INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 114048 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 67-5028 | 01 | TX | MEDICARE SNF | OTHER |