Provider Demographics
NPI:1033544853
Name:DIVERSICARE OF ST. THERESA, LLC
Entity Type:Organization
Organization Name:DIVERSICARE OF ST. THERESA, LLC
Other - Org Name:DIVERSICARE OF ST. THERESA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCKNIGHT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:7010 ROWAN HILL DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45227-3380
Mailing Address - Country:US
Mailing Address - Phone:513-271-7010
Mailing Address - Fax:513-527-0181
Practice Address - Street 1:7010 ROWAN HILL DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45227-3380
Practice Address - Country:US
Practice Address - Phone:513-271-7010
Practice Address - Fax:513-527-0181
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-11
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0096325Medicaid