Provider Demographics
NPI:1871919431
Name:SOUTHWEST LTC - WATERTON LLC
Entity type:Organization
Organization Name:SOUTHWEST LTC - WATERTON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
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 200
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 1:2875 SHILOH RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2936
Practice Address - Country:US
Practice Address - Phone:903-561-1300
Practice Address - Fax:903-939-1754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-06
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103323Medicaid
TX676193Medicare Oscar/Certification