Basic Information
| Provider Information | |||||||||
| NPI: | 1376837138 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST LTC KELLER, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HERITAGE HOUSE OF KELLER HEALTH & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 WHITLEY RD | ||||||||
| Address2: | |||||||||
| City: | KELLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762483038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174312518 | ||||||||
| FaxNumber: | 4699166105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1150 WHITLEY RD | ||||||||
| Address2: | |||||||||
| City: | KELLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762483038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174312518 | ||||||||
| FaxNumber: | 4699166105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 11/29/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PAYNE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4699166100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.