# DIVERSICARE LEASING CORP.

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- **Entity:** Organization
- **Status:** Active
- **Other names:** South Shore Nursing & Rehabilitation Center
- **Organization subpart:** No

## Provider details

- **NPI number:** 1477541688
- **Authorized official:** RAYMOND L. TYLER JR. (EXECUTIVE VICE PRESIDENT AND COO)
- **Authorized official phone:** (615) 771-7575

## Contact information

- **Practice address:** 489 JAMES HANNAH DRIVE, SOUTH SHORE, KY 41175-0489
- **Practice address phone:** (606) 932-3127
- **Practice address fax:** (606) 932-4663
- **Mailing address:** PO BOX 489, JAMES HANNAH DRIVE, SOUTH SHORE, KY 41175-0489
- **Mailing address phone:** (606) 932-3127
- **Mailing address fax:** (606) 932-4663

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 100156 | KY | Yes |

## Other

- **Enumeration date:** 10/11/2005
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 12503025 | — | KY |