Basic Information
| Provider Information | |||||||||
| NPI: | 1629493028 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST LTC - REUNION PLAZA LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | REUNION PLAZA HEALTHCARE & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5560 TENNYSON PKWY STE 210 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750243582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4699166100 | ||||||||
| FaxNumber: | 4699166105 | ||||||||
| Practice Location | |||||||||
| Address1: | 1401 RICE RD | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757033233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035616060 | ||||||||
| FaxNumber: | 9035348045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2014 | ||||||||
| LastUpdateDate: | 02/08/2022 | ||||||||
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| AuthorizedOfficialLastName: | PAYNE | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4699166100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/08/2022 | ||||||||
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 | 005461 | 05 | TX | MEDICAID |