Diversicare of Canon City, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

DIVERSICARE OF CANON CITY, LLC

Practice address

515 Fairview Ave
Canon City, CO 81212-2863

Phone

(719) 275-0665

Fax

(615) 620-7875

NPI assigned

May 23, 2015

Organization subpart

Yes

Parent organization

DIVERSICARE LEASING COMPANY II, LLCAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Kelly J Gill

Title

President & Ceo

Phone

(615) 771-7575

Specialties & licenses 1

Addresses

Other names 1

• Diversicare of Canon City Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1432339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1432339200000",
    "number": "1497134456",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "515 FAIRVIEW AVE",
            "city": "CANON CITY",
            "state": "CO",
            "postal_code": "812122863",
            "telephone_number": "719-275-0665",
            "fax_number": "615-620-7875"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "515 FAIRVIEW AVE",
            "city": "CANON CITY",
            "state": "CO",
            "postal_code": "812122863",
            "telephone_number": "719-275-0665",
            "fax_number": "615-620-7875"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DIVERSICARE OF CANON CITY, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DIVERSICARE LEASING COMPANY II, LLC",
        "enumeration_date": "2015-05-23",
        "last_updated": "2015-05-23",
        "status": "A",
        "authorized_official_last_name": "GILL",
        "authorized_official_first_name": "KELLY",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRESIDENT & CEO",
        "authorized_official_telephone_number": "615-771-7575"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Diversicare of Canon City",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Developmental Opportunities
• Developmental Opportunities
• Cherilyn Wyquita Dewitt, BS
• Mark Wayne Diamond, D.O.
• Dillon Companies LLC
• Doc
• Joanie Amba Dockins, RN
• Brian Leslie Dodds, MD
• Alan Donald, CAC II
• Danika Donovan

• Skilled Nursing Facility in Canon City, CO
• Providers in Canon City, CO by specialty
• Skilled Nursing Facility in Colorado

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 23, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.