MEDICARE: SOUTHWEST LTC CROCKETT II, LTD.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326111659
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST LTC CROCKETT II, LTD.

Provider Business Mailing Address
First Line	:	17760 PRESTON RD
Second Line	:	SUITE 310
City	:	DALLAS
State	:	TX
Zip	:	75252-5663
Country	:	US
Telephone Number	:	469-916-6100
Fax Number	:	469-916-6105

Provider Business Practice Location Address
First Line	:	1108 EAST LOOP 304
Second Line	:
City	:	CROCKETT
State	:	TX
Zip	:	75835-1810
Country	:	US
Telephone Number	:	936-544-0150
Fax Number	:	936-544-2929

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	RONALD R. PAYNE
Credential	:
Telephone Number	:	469-916-6100

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	08/22/2020

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