Provider Demographics
NPI:1558769505
Name:DIVERSICARE OF GLASGOW, LLC
Entity Type:Organization
Organization Name:DIVERSICARE OF GLASGOW, LLC
Other - Org Name:DIVERSICARE OF GLASGOW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND 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 1:300 WESTWOOD ST
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1030
Mailing Address - Country:US
Mailing Address - Phone:270-651-9131
Mailing Address - Fax:615-620-7875
Practice Address - Street 1:300 WESTWOOD ST
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1030
Practice Address - Country:US
Practice Address - Phone:270-651-9131
Practice Address - Fax:615-620-7875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE HEALTHCARE SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-08
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100509314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY185229Medicare Oscar/Certification