1659369627 NPI number — DIVERSICARE AFTON OAKS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659369627 NPI number — DIVERSICARE AFTON OAKS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIVERSICARE AFTON OAKS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AFTON OAKS NURSING & REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659369627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1621 GALLERIA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-2926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-550-9453
Provider Business Mailing Address Fax Number:
615-915-6935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7514 KINGSLEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77087-4412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-644-8393
Provider Business Practice Location Address Fax Number:
713-641-0597
Provider Enumeration Date:
10/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WEISHAAR
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
615-550-9459

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  112912 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001001790 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4774 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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