Provider Demographics
NPI:1386631182
Name:DIVERSICARE LEASING LP
Entity Type:Organization
Organization Name:DIVERSICARE LEASING LP
Other - Org Name:LYNWOOD NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEISHAAR
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:615-550-9459
Mailing Address - Street 1:4164 HALLS MILL RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-5614
Mailing Address - Country:US
Mailing Address - Phone:251-661-5404
Mailing Address - Fax:251-661-5407
Practice Address - Street 1:4164 HALLS MILL RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-5614
Practice Address - Country:US
Practice Address - Phone:251-661-5404
Practice Address - Fax:251-661-5407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALN4907314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL47-54270SMedicaid
AL01-5434Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER