Healthcare Provider Details

I. General information

NPI: 1639560337
Provider Name (Legal Business Name): SOUTHWEST LTC - TEMPLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2015
Last Update Date: 08/03/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WEST GREEN AVE
TEMPLE OK
73568
US

IV. Provider business mailing address

5560 TENNYSON PKWY STE 210
PLANO TX
75024-3582
US

V. Phone/Fax

Practice location:
  • Phone: 580-342-6228
  • Fax:
Mailing address:
  • Phone: 469-916-6100
  • Fax: 469-916-6105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: RONALD PAYNE
Title or Position: MANAGER
Credential:
Phone: 469-916-6100