# DIVERSICARE LEASING CORP.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Chisolm Trail Nursing & Rehabilitation Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1376531343
- **Authorized official:** RAYMOND L. TYLER JR. (EXECUTIVE VICE PRESIDENT AND COO)
- **Authorized official phone:** (615) 771-7575

## Contact information

- **Practice address:** 107 N MEDINA ST, LOCKHART, TX 78644-1919
- **Practice address phone:** (512) 398-5213
- **Practice address fax:** (512) 376-6880
- **Mailing address:** 107 N MEDINA ST, LOCKHART, TX 78644-1919
- **Mailing address phone:** (512) 398-5213
- **Mailing address fax:** (512) 376-6880

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 115093 | TX | Yes |

## Other

- **Enumeration date:** 10/12/2005
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 4891 | — | TX |