Healthcare Provider Details

I. General information

NPI: 1861884348
Provider Name (Legal Business Name): SOUTHWEST LTC TUTTLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SE 4TH ST
TUTTLE OK
73089-8825
US

IV. Provider business mailing address

1518 LEGACY DR SUITE 110
FRISCO TX
75034-6038
US

V. Phone/Fax

Practice location:
  • Phone: 405-381-3363
  • 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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200093870B
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

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