Basic Information
| Provider Information | |||||||||
| NPI: | 1114306172 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIVERSICARE OF LARAMIE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | DIVERSICARE OF LARAMIE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 503 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820704303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077423728 | ||||||||
| FaxNumber: | 6156207875 | ||||||||
| Practice Location | |||||||||
| Address1: | 503 S 18TH ST | ||||||||
| Address2: | |||||||||
| City: | LARAMIE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820704303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3077423728 | ||||||||
| FaxNumber: | 6156207875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2015 | ||||||||
| LastUpdateDate: | 05/23/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GILL | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 6157717575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIVERSICARE LEASING COMPANY II, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.