MEDICARE: SOUTHWEST LTC GULF HEALTHCARE 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	005322	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	:	1023002102
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST LTC GULF HEALTHCARE LTD

Provider Business Mailing Address
First Line	:	1518 LEGACY DR
Second Line	:	SUITE 110
City	:	FRISCO
State	:	TX
Zip	:	75034-6038
Country	:	US
Telephone Number	:	469-916-6100
Fax Number	:	469-916-6105

Provider Business Practice Location Address
First Line	:	6600 9TH AVE
Second Line	:
City	:	PORT ARTHUR
State	:	TX
Zip	:	77642-6411
Country	:	US
Telephone Number	:	469-916-6100
Fax Number	:	469-916-6105

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

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	06/02/2015

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Directions to “SOUTHWEST LTC GULF HEALTHCARE LTD ” Practice Location

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