Provider Demographics
NPI:1437191285
Name:DIVERSICARE CHISOLM, LLC
Entity Type:Organization
Organization Name:DIVERSICARE CHISOLM, LLC
Other - Org Name:CHISOLM TRAIL NURSING & REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
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:615-915-9635
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?:Yes
Parent Organization LBN:DIVERSICARE LEASING LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-12
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX137734314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4891Medicaid
TX67-5053Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER