Basic Information
| Provider Information | |||||||||
| NPI: | 1134117666 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FT. WORTH SOUTHWEST NURSING CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHWEST NURSING & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 E WHALEY ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756016525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037575360 | ||||||||
| FaxNumber: | 9037538621 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 ALTA MESA BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761335924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173461800 | ||||||||
| FaxNumber: | 8173460149 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 09/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | STEBBINS | ||||||||
| AuthorizedOfficialFirstName: | DICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER/MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9037575360 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 100222 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 022645801 | 05 | TX | MEDICAID | 001001513 | 05 | TX | MEDICAID |