Healthcare Provider Details

I. General information

NPI: 1467439976
Provider Name (Legal Business Name): SOUTHWEST LTC--BRADY WEST, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 MENARD HWY
BRADY TX
76825-7432
US

IV. Provider business mailing address

17760 PRESTON RD SUITE 310
DALLAS TX
75252-5663
US

V. Phone/Fax

Practice location:
  • Phone: 325-597-2906
  • Fax: 325-597-2555
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 Number004744
License Number StateTX

VIII. Authorized Official

Name: MR. RONALD R. PAYNE
Title or Position: MANAGING MEMBER
Credential: ESQ.
Phone: 469-916-6100