Provider Demographics
NPI:1033772413
Name:SOUTHWEST LTC - BONNER LLC
Entity Type:Organization
Organization Name:SOUTHWEST LTC - BONNER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-916-6100
Mailing Address - Street 1:5560 TENNYSON PKWY STE 210
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3582
Mailing Address - Country:US
Mailing Address - Phone:469-916-6100
Mailing Address - Fax:
Practice Address - Street 1:810 BELLAIRE ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-9045
Practice Address - Country:US
Practice Address - Phone:903-589-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-21
Last Update Date:2019-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility