Basic Information
| Provider Information | |||||||||
| NPI: | 1972058055 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIVERSICARE OF HUEYTOWN, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BARON HOUSE OF HUEYTOWN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 190 BROOKLANE DR | ||||||||
| Address2: | |||||||||
| City: | HUEYTOWN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350232368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054912905 | ||||||||
| FaxNumber: | 6156207875 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 BROOKLANE DR | ||||||||
| Address2: | |||||||||
| City: | HUEYTOWN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350232368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054912905 | ||||||||
| FaxNumber: | 6156207875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2016 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WEISHAAR | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER & SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6157717575 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DIVERSICARE HEALTHCARE SERVICES LLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | AL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 199000 | 05 | AL | MEDICAID |