Basic Information
| Provider Information | |||||||||
| NPI: | 1487642054 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIVERSICARE LEASING CORP. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EUREKA SPRINGS NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 235 HUNTSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | EUREKA SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726329572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792537038 | ||||||||
| FaxNumber: | 4792532508 | ||||||||
| Practice Location | |||||||||
| Address1: | 235 HUNTSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | EUREKA SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726329572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792537038 | ||||||||
| FaxNumber: | 4792532508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TYLER | ||||||||
| AuthorizedOfficialFirstName: | RAYMOND | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT AND COO | ||||||||
| AuthorizedOfficialTelephone: | 6157717575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 533 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.