Provider Demographics
NPI:1972844744
Name:DIVERSICARE OF COUNCIL GROVE LLC
Entity Type:Organization
Organization Name:DIVERSICARE OF COUNCIL GROVE LLC
Other - Org Name:DIVERSICARE OF COUNCIL GROVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
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:615-550-9459
Mailing Address - Street 1:1621 GALLERIA BLVD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2926
Mailing Address - Country:US
Mailing Address - Phone:615-550-9453
Mailing Address - Fax:615-915-6935
Practice Address - Street 1:400 SUNSET DR
Practice Address - Street 2:
Practice Address - City:COUNCIL GROVE
Practice Address - State:KS
Practice Address - Zip Code:66846-1554
Practice Address - Country:US
Practice Address - Phone:620-767-5172
Practice Address - Fax:620-767-6622
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE KANSAS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-04
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility