1861884348 NPI number — SOUTHWEST LTC TUTTLE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861884348 NPI number — SOUTHWEST LTC TUTTLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST LTC TUTTLE LLC
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:
TUTTLE CARE 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:
1861884348
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1518 LEGACY DR
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
FRISCO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75034-6038
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:
104 SE 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUTTLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73089-8825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-381-3363
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/20/2015

Additional Information

Authorized Official

Authorized Official Last Name:
PAYNE
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
469-916-6100

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200093870B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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