Provider Demographics
NPI:1023002706
Name:SOUTHWEST LTC--GRANBURY, LTD.
Entity Type:Organization
Organization Name:SOUTHWEST LTC--GRANBURY, LTD.
Other - Org Name:GRANBERRY VILLA NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:R
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:ESQ
Authorized Official - Phone:469-916-6100
Mailing Address - Street 1:17760 PRESTON RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75252-5663
Mailing Address - Country:US
Mailing Address - Phone:469-916-6100
Mailing Address - Fax:469-916-6105
Practice Address - Street 1:2124 PALUXY HWY
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5530
Practice Address - Country:US
Practice Address - Phone:817-279-7600
Practice Address - Fax:817-279-7602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113575314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility