Healthcare Provider Details

I. General information

NPI: 1750632675
Provider Name (Legal Business Name): GREATER SOUTHWEST MEDICAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 IRA E WOODS AVE 200
GRAPEVINE TX
76051-4008
US

IV. Provider business mailing address

815 IRA E WOODS AVE 200
GRAPEVINE TX
76051-4008
US

V. Phone/Fax

Practice location:
  • Phone: 817-488-0100
  • Fax: 817-488-4568
Mailing address:
  • Phone: 817-488-0100
  • Fax: 817-488-4568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberF0809323
License Number StateTX

VIII. Authorized Official

Name: DR. IRBY HUNTER JR.
Title or Position: ADMINISTRATOR
Credential: M.D.
Phone: 817-488-0100