Provider Demographics
NPI:1225026800
Name:DIVERSICARE LEASING CORP.
Entity Type:Organization
Organization Name:DIVERSICARE LEASING CORP.
Other - Org Name:WALNUT RIDGE NURSING AND 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 1:1500 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-1434
Mailing Address - Country:US
Mailing Address - Phone:870-886-9022
Mailing Address - Fax:870-886-8001
Practice Address - Street 1:1500 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1434
Practice Address - Country:US
Practice Address - Phone:870-886-9022
Practice Address - Fax:870-886-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR539314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR04-5151Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER