Provider Demographics
NPI:1508291329
Name:DIVERSICARE OF BRADFORD PLACE, LLC
Entity Type:Organization
Organization Name:DIVERSICARE OF BRADFORD PLACE, LLC
Other - Org Name:DIVERSICARE OF BRADFORD PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:MCKNIGHT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:1302 MILLVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45013-3961
Mailing Address - Country:US
Mailing Address - Phone:513-867-4100
Mailing Address - Fax:513-867-1415
Practice Address - Street 1:1302 MILLVILLE AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45013-3961
Practice Address - Country:US
Practice Address - Phone:513-867-4100
Practice Address - Fax:513-867-1415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-09-11
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0096324Medicaid