Provider Demographics
NPI:1447705439
Name:DIVERSICARE OF TUPELO, LLC
Entity type:Organization
Organization Name:DIVERSICARE OF TUPELO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:2273 S EASON BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-5900
Practice Address - Country:US
Practice Address - Phone:662-842-2461
Practice Address - Fax:662-841-2884
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DIVERSICARE LEASING COMPANY III, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-18
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS417314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00023145Medicaid
MS255105Medicare Oscar/Certification