Provider Demographics
NPI:1215314497
Name:DIVERSICARE OF SEINA WOODS, LLC
Entity type:Organization
Organization Name:DIVERSICARE OF SEINA WOODS, 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 1:6125 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-3110
Mailing Address - Country:US
Mailing Address - Phone:937-278-8211
Mailing Address - Fax:937-278-8046
Practice Address - Street 1:6125 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-3110
Practice Address - Country:US
Practice Address - Phone:937-278-8211
Practice Address - Fax:937-278-8046
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY II, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2379R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH36-5819OtherMEDICARE