Provider Demographics
NPI:1558893701
Name:SOUTHWEST LTC - FORT WORTH ALF, LLC
Entity Type:Organization
Organization Name:SOUTHWEST LTC - FORT WORTH ALF, LLC
Other - Org Name:COLONIAL GARDENS OF FORT WORTH FW-1
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:R
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:469-916-6105
Practice Address - Street 1:6939 RIVER PARK CIR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-8465
Practice Address - Country:US
Practice Address - Phone:817-731-7611
Practice Address - Fax:817-731-4909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-28
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility