MEDICARE: SOUTHWEST LTC - FORT WORTH ALF, LLC

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	310400000X	Assisted Living Facility	145897	TX

General Provider Information

NPI Number	:	1760914469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWEST LTC - FORT WORTH ALF, LLC

Provider Business Mailing Address
First Line	:	5560 TENNYSON PKWY STE 210
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-3582
Country	:	US
Telephone Number	:	469-916-6100
Fax Number	:	469-916-6105

Provider Business Practice Location Address
First Line	:	6931 RIVER PARK CIR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-8465
Country	:	US
Telephone Number	:	817-731-7611
Fax Number	:	817-731-4909

Authorized Official
Title or Position	:	MANAGER
Name	:	RONALD PAYNE
Credential	:
Telephone Number	:	469-916-6100

Provider Enumeration Date	:	03/31/2017
Last Update Date	:	11/11/2021

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