1467439976 NPI number — SOUTHWEST LTC--BRADY WEST, LTD.

Table of content: (NPI 1467439976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467439976 NPI number — SOUTHWEST LTC--BRADY WEST, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST LTC--BRADY WEST, LTD.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BRADY WEST NURSING AND CONVALESCENT CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467439976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17760 PRESTON RD
Provider Second Line Business Mailing Address:
SUITE 310
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75252-5663
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-916-6100
Provider Business Mailing Address Fax Number:
469-916-6105

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2201 MENARD HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRADY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76825-7432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-597-2906
Provider Business Practice Location Address Fax Number:
325-597-2555
Provider Enumeration Date:
12/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PAYNE
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
469-916-6100

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  004744 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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