Provider Demographics
NPI:1376531343
Name:DIVERSICARE LEASING CORP.
Entity Type:Organization
Organization Name:DIVERSICARE LEASING CORP.
Other - Org Name:CHISOLM TRAIL 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 1:107 N MEDINA ST
Mailing Address - Street 2:
Mailing Address - City:LOCKHART
Mailing Address - State:TX
Mailing Address - Zip Code:78644-1919
Mailing Address - Country:US
Mailing Address - Phone:512-398-5213
Mailing Address - Fax:512-376-6880
Practice Address - Street 1:107 N MEDINA ST
Practice Address - Street 2:
Practice Address - City:LOCKHART
Practice Address - State:TX
Practice Address - Zip Code:78644-1919
Practice Address - Country:US
Practice Address - Phone:512-398-5213
Practice Address - Fax:512-376-6880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115093314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4891Medicaid
TX67-5053Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER