Provider Demographics
NPI:1619287273
Name:SOUTHWEST LTC KILGORE LTD
Entity Type:Organization
Organization Name:SOUTHWEST LTC KILGORE LTD
Other - Org Name:THE WILLOWS OF KILGORE
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 1:1901 WHIPPORWILL LN
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3880
Mailing Address - Country:US
Mailing Address - Phone:903-983-7775
Mailing Address - Fax:903-984-2244
Practice Address - Street 1:1901 WHIPPORWILL LN
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3880
Practice Address - Country:US
Practice Address - Phone:903-983-7775
Practice Address - Fax:903-984-2244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility