Provider Demographics
NPI:1891102760
Name:DIVERSICARE OF AVON, LLC
Entity Type:Organization
Organization Name:DIVERSICARE OF AVON, LLC
Other - Org Name:AVON PLACE
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 1:32900 DETROIT RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:OH
Mailing Address - Zip Code:44011-2018
Mailing Address - Country:US
Mailing Address - Phone:440-937-6201
Mailing Address - Fax:440-937-5955
Practice Address - Street 1:32900 DETROIT RD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-2018
Practice Address - Country:US
Practice Address - Phone:440-937-6201
Practice Address - Fax:440-937-5955
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-12
Last Update Date:2014-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility