Basic Information
| Provider Information | |||||||||
| NPI: | 1588055206 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST LTC LAWTON LLC | ||||||||
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| OtherOrganizationName: | WILLOW PARK HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1518 LEGACY DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | FRISCO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750346038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4699166100 | ||||||||
| FaxNumber: | 4699166105 | ||||||||
| Practice Location | |||||||||
| Address1: | 7019 NW CACHE RD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735052707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4699166100 | ||||||||
| FaxNumber: | 4699166105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2015 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | PAYNE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4699166100 | ||||||||
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| 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 |
ID Information
| ID | Type | State | Issuer | Description | 200102040A | 05 | OK | MEDICAID |