Provider Demographics
NPI:1174511398
Name:DIVERSICARE LEASING CORP.
Entity Type:Organization
Organization Name:DIVERSICARE LEASING CORP.
Other - Org Name:BOYD NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT AND COO
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:L
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:12800 PRINCELAND DR
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41102-9681
Mailing Address - Country:US
Mailing Address - Phone:606-928-2963
Mailing Address - Fax:606-928-3879
Practice Address - Street 1:12800 PRINCELAND DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-9681
Practice Address - Country:US
Practice Address - Phone:606-928-2963
Practice Address - Fax:606-928-3879
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVOCAT INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-11
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100689314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12503082Medicaid
KY12503082Medicaid