Provider Demographics
NPI:1053511998
Name:DIVERSICARE ESTATES LLC
Entity Type:Organization
Organization Name:DIVERSICARE ESTATES LLC
Other - Org Name:ESTATES HEALTHCARE AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:201 SYCAMORE SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76134-5009
Mailing Address - Country:US
Mailing Address - Phone:817-293-7610
Mailing Address - Fax:817-293-5766
Practice Address - Street 1:201 SYCAMORE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76134-5009
Practice Address - Country:US
Practice Address - Phone:817-293-7610
Practice Address - Fax:817-293-5766
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVOCAT INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-19
Last Update Date:2012-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114048314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX67-5028OtherMEDICARE SNF
TX67-5028OtherMEDICARE SNF