Basic Information
| Provider Information | |||||||||
| NPI: | 1801341896 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIVERSICARE OF SOUTHAVEN, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIVERSICARE OF SOUTHAVEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 DORCHESTER DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386715723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623930050 | ||||||||
| FaxNumber: | 6156207875 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 DORCHESTER DR | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386715723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623930050 | ||||||||
| FaxNumber: | 6156207875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2016 | ||||||||
| LastUpdateDate: | 02/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | GILL | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6157717575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIVERSICARE LEASING COMPANY III, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 388 | MS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00023137 | 05 | MS | MEDICAID |