Provider Demographics
NPI:1477541688
Name:DIVERSICARE LEASING CORP.
Entity Type:Organization
Organization Name:DIVERSICARE LEASING CORP.
Other - Org Name:SOUTH SHORE 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:PO BOX 489
Mailing Address - Street 2:JAMES HANNAH DRIVE
Mailing Address - City:SOUTH SHORE
Mailing Address - State:KY
Mailing Address - Zip Code:41175-0489
Mailing Address - Country:US
Mailing Address - Phone:606-932-3127
Mailing Address - Fax:606-932-4663
Practice Address - Street 1:489 JAMES HANNAH DRIVE
Practice Address - Street 2:
Practice Address - City:SOUTH SHORE
Practice Address - State:KY
Practice Address - Zip Code:41175-0489
Practice Address - Country:US
Practice Address - Phone:606-932-3127
Practice Address - Fax:606-932-4663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100156314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12503025Medicaid
KY18-5282Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER