Provider Demographics
NPI:1134117666
Name:FT. WORTH SOUTHWEST NURSING CENTER, LLC
Entity Type:Organization
Organization Name:FT. WORTH SOUTHWEST NURSING CENTER, LLC
Other - Org Name:SOUTHWEST NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DICK
Authorized Official - Middle Name:
Authorized Official - Last Name:STEBBINS
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:903-757-5360
Mailing Address - Street 1:600 E WHALEY ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6525
Mailing Address - Country:US
Mailing Address - Phone:903-757-5360
Mailing Address - Fax:903-753-8621
Practice Address - Street 1:5300 ALTA MESA BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-5924
Practice Address - Country:US
Practice Address - Phone:817-346-1800
Practice Address - Fax:817-346-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100222314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX022645801Medicaid
TX001001513Medicaid
TX022645801Medicaid