# FORTH WORTH MANOR INC

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

## Provider details

- **NPI number:** 1891782298
- **Authorized official:** JANICE PITA (INSURANCE/MEDICARE)
- **Authorized official phone:** (580) 622-6300

## Contact information

- **Practice address:** 110 W MUSKOGEE AVE, SULPHUR, OK 73086-4810
- **Practice address phone:** (580) 622-6300
- **Practice address fax:** (580) 622-8344
- **Mailing address:** 4900 E BERRY ST, FORT WORTH, TX 76105-4314
- **Mailing address phone:** (817) 531-3707
- **Mailing address fax:** (817) 536-1648

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 313M00000X | Nursing Facility/Intermediate Care Facility | 113559 | TX | Yes |

## Other

- **Enumeration date:** 09/30/2005
- **Last updated:** 06/16/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 001012189 | — | TX |
| 01 | — | HH320S | BLUE CROSS BLUE SHIELD | TX |