Basic Information
| Provider Information | |||||||||
| NPI: | 1326111659 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST LTC CROCKETT II, LTD. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WINFIELD NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17760 PRESTON RD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752525663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4699166100 | ||||||||
| FaxNumber: | 4699166105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 EAST LOOP 304 | ||||||||
| Address2: | |||||||||
| City: | CROCKETT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 758351810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9365440150 | ||||||||
| FaxNumber: | 9365442929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAYNE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4699166100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 5125 | 05 | TX | MEDICAID |