Provider Demographics
NPI:1720076771
Name:DIVERSICARE LEASING CORP.
Entity Type:Organization
Organization Name:DIVERSICARE LEASING CORP.
Other - Org Name:ELLIOTT NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT AND COO
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:L
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:615-771-7575
Mailing Address - Street 1:PO BOX 694
Mailing Address - Street 2:RTE 32 E HOWARD CREEK RD
Mailing Address - City:SANDY HOOK
Mailing Address - State:KY
Mailing Address - Zip Code:41171-0694
Mailing Address - Country:US
Mailing Address - Phone:606-738-9400
Mailing Address - Fax:606-738-9410
Practice Address - Street 1:RTE 32 E HOWARD CREEK RD
Practice Address - Street 2:
Practice Address - City:SANDY HOOK
Practice Address - State:KY
Practice Address - Zip Code:41171
Practice Address - Country:US
Practice Address - Phone:606-738-9400
Practice Address - Fax:606-738-9410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100690314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12503066Medicaid
KY18-5415Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER