Provider Demographics
NPI:1568719045
Name:DIVERSICARE HIGHLANDS, LLC
Entity Type:Organization
Organization Name:DIVERSICARE HIGHLANDS, LLC
Other - Org Name:HIGHLANDS HEALTH AND REHABILITATION CENTER
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 1:1705 STEVENS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-1044
Mailing Address - Country:US
Mailing Address - Phone:502-451-9330
Mailing Address - Fax:615-620-7875
Practice Address - Street 1:1705 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1044
Practice Address - Country:US
Practice Address - Phone:502-451-9330
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:2012-08-14
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100229500Medicaid
KY185039Medicare Oscar/Certification