# HENNESSEY MANOR NURSING HOME INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Legacy Living Centers
- **Organization subpart:** No

## Provider details

- **NPI number:** 1427046796
- **Authorized official:** JANICE PITA (INSURANCE/MEDICARE)
- **Authorized official phone:** (580) 622-6300

## Contact information

- **Practice address:** 705 E 3RD ST, HENNESSEY, OK 73742-1620
- **Practice address phone:** (405) 853-6027
- **Practice address fax:** (405) 853-4389
- **Mailing address:** 705 E 3RD ST, HENNESSEY, OK 73742-1620
- **Mailing address phone:** (405) 853-6027
- **Mailing address fax:** (405) 853-4389

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 313M00000X | Nursing Facility/Intermediate Care Facility | NH3703-3703 | OK | Yes |

## Other

- **Enumeration date:** 10/11/2005
- **Last updated:** 05/22/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 200059260A | — | OK |
| 01 | — | 731473404001 | BLUE CROSS BLUE SHIELD OK | OK |