Basic Information
Provider Information | |||||||||
NPI: | 1245224237 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHWEST LTC GULF HEALTHCARE LTD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GULF HEALTHCARE CENTER GALVESTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1518 LEGACY DR | ||||||||
Address2: | SUITE 110 | ||||||||
City: | FRISCO | ||||||||
State: | TX | ||||||||
PostalCode: | 750346038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4699166100 | ||||||||
FaxNumber: | 4699166105 | ||||||||
Practice Location | |||||||||
Address1: | 3702 COVE VIEW BLVD | ||||||||
Address2: |   | ||||||||
City: | GALVESTON | ||||||||
State: | TX | ||||||||
PostalCode: | 775548013 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4097407330 | ||||||||
FaxNumber: | 4094077640 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2005 | ||||||||
LastUpdateDate: | 06/02/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PAYNE | ||||||||
AuthorizedOfficialFirstName: | RONALD | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 4969166100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | ESQ. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 005330 | TX | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 5330 | 05 | TX |   | MEDICAID |