# SOUTHWEST LTC - WATERTON LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** The Waterton Healthcare & Rehabilitation
- **Organization subpart:** No

## Provider details

- **NPI number:** 1871919431
- **Authorized official:** RONALD PAYNE (MANAGER)
- **Authorized official phone:** (469) 916-6100

## Contact information

- **Practice address:** 2875 SHILOH RD, TYLER, TX 75703-2936
- **Practice address phone:** (903) 561-1300
- **Practice address fax:** (903) 939-1754
- **Mailing address:** 5560 TENNYSON PKWY STE 200, PLANO, TX 75024-3582
- **Mailing address phone:** (469) 916-6100
- **Mailing address fax:** (469) 916-6105

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | — | — | Yes |

## Other

- **Enumeration date:** 03/06/2014
- **Last updated:** 02/08/2022

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 103323 | — | TX |