Provider Demographics
NPI:1306833694
Name:DIVERSICARE LEASING LP
Entity Type:Organization
Organization Name:DIVERSICARE LEASING LP
Other - Org Name:CANTERBURY HEALTHCARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEISHAAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:1720 KNOWLES RD
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36869-7135
Mailing Address - Country:US
Mailing Address - Phone:334-291-0486
Mailing Address - Fax:334-297-5816
Practice Address - Street 1:1720 KNOWLES RD
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36869-7135
Practice Address - Country:US
Practice Address - Phone:334-291-0486
Practice Address - Fax:334-297-5816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-01
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALN5704314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL47-57740SMedicaid
AL01-5382Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER