Provider Demographics
NPI:1477008464
Name:DIVERSICARE OF CARTHAGE, LLC
Entity Type:Organization
Organization Name:DIVERSICARE OF CARTHAGE, LLC
Other - Org Name:DIVERSICARE OF CARTHAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:1101 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:MS
Mailing Address - Zip Code:39051-3603
Mailing Address - Country:US
Mailing Address - Phone:601-267-4551
Mailing Address - Fax:615-620-7875
Practice Address - Street 1:1101 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051-3603
Practice Address - Country:US
Practice Address - Phone:601-267-4551
Practice Address - Fax:615-620-7875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY III, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-18
Last Update Date:2017-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS378314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00023024Medicaid
MS255108Medicare Oscar/Certification