Provider Demographics
NPI:1114306172
Name:DIVERSICARE OF LARAMIE, LLC
Entity Type:Organization
Organization Name:DIVERSICARE OF LARAMIE, LLC
Other - Org Name:DIVERSICARE OF LARAMIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & 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 1:503 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-4303
Mailing Address - Country:US
Mailing Address - Phone:307-742-3728
Mailing Address - Fax:615-620-7875
Practice Address - Street 1:503 S 18TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4303
Practice Address - Country:US
Practice Address - Phone:307-742-3728
Practice Address - Fax:615-620-7875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-23
Last Update Date:2015-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility