Basic Information
| Provider Information | |||||||||
| NPI: | 1265973457 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIVERSICARE OF SELMA, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PARK PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PARK PL | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367017743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348723471 | ||||||||
| FaxNumber: | 6156207875 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PARK PL | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3348723471 | ||||||||
| FaxNumber: | 6156207875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2017 | ||||||||
| LastUpdateDate: | 08/07/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCKNIGHT | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 6157717575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIVERSICARE HOLDING COMPANY, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N2402 | AL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 206565 | 05 | AL | MEDICAID |