Provider Demographics
NPI:1104117761
Name:DIVERSICARE ROSE TERRACE, LLC
Entity type:Organization
Organization Name:DIVERSICARE ROSE TERRACE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:30 HIDDEN BROOK WAY
Mailing Address - Street 2:
Mailing Address - City:CULLODEN
Mailing Address - State:WV
Mailing Address - Zip Code:25510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 HIDDEN BROOK WAY
Practice Address - Street 2:
Practice Address - City:CULLODEN
Practice Address - State:WV
Practice Address - Zip Code:25510
Practice Address - Country:US
Practice Address - Phone:615-771-7575
Practice Address - Fax:615-620-7875
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVOCAT INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-29
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV183314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023465Medicaid
WV51-5192OtherMEDICARE SNF
WV3810023465Medicaid