Provider Demographics
NPI:1447631494
Name:SOUTHWEST LTC - QUAIL CREEK, LLC
Entity type:Organization
Organization Name:SOUTHWEST LTC - QUAIL CREEK, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-916-6100
Mailing Address - Street 1:5560 TENNYSON PKWY STE 210
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3582
Mailing Address - Country:US
Mailing Address - Phone:469-916-6100
Mailing Address - Fax:469-916-6105
Practice Address - Street 1:13500 BRANDON PL
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-4312
Practice Address - Country:US
Practice Address - Phone:405-720-0010
Practice Address - Fax:405-720-1397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK375119Medicare Oscar/Certification