Provider Demographics
NPI:1821086562
Name:DIVERSICARE LEASING LP
Entity Type:Organization
Organization Name:DIVERSICARE LEASING LP
Other - Org Name:BROOKSHIRE HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEISHAAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:4320 JUDITH LN SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-3363
Mailing Address - Country:US
Mailing Address - Phone:256-837-1730
Mailing Address - Fax:256-430-3287
Practice Address - Street 1:4320 JUDITH LN SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-3363
Practice Address - Country:US
Practice Address - Phone:256-837-1730
Practice Address - Fax:256-430-3287
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DLC GP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-06
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALN4504314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL47-57660SMedicaid
AL01-5127Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER