Provider Demographics
NPI:1073920948
Name:DIVERSICARE OF MANSFIELD, LLC
Entity Type:Organization
Organization Name:DIVERSICARE OF MANSFIELD, LLC
Other - Org Name:ONTARIO POINTE
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 1:2124 PARK AVE W
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3807
Mailing Address - Country:US
Mailing Address - Phone:419-529-6447
Mailing Address - Fax:419-529-2108
Practice Address - Street 1:2124 PARK AVE W
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OH
Practice Address - Zip Code:44906-3807
Practice Address - Country:US
Practice Address - Phone:419-529-6447
Practice Address - Fax:419-529-2108
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-12
Last Update Date:2014-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility