Provider Demographics
NPI:1417690157
Name:DAC OF GREENSBORO, LLC
Entity Type:Organization
Organization Name:DAC OF GREENSBORO, LLC
Other - Org Name:DIVERSICARE OF GREENSBORO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
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:615-550-9459
Mailing Address - Street 1:1621 GALLERIA BLVD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2926
Mailing Address - Country:US
Mailing Address - Phone:615-550-9453
Mailing Address - Fax:615-915-6935
Practice Address - Street 1:616 ARMORY ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:AL
Practice Address - Zip Code:36744-2110
Practice Address - Country:US
Practice Address - Phone:334-624-3054
Practice Address - Fax:334-624-7560
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAC ACQUISITION LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-20
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01-5396OtherMEDICARE - PTAN