Organization
FORTH WORTH MANOR INC
Active
Other names
Legacy Living Centers
Organization subpart
No
Provider details
NPI number
Authorized official
JANICE PITA (INSURANCE/MEDICARE)
(580) 622-6300
Entity
Organization
Contact information
Practice address
110 W MUSKOGEE AVE, SULPHUR, OK 73086-4810
(580) 622-6300
(580) 622-8344
Mailing address
4900 E BERRY ST, FORT WORTH, TX 76105-4314
(817) 531-3707
(817) 536-1648
Taxonomy
Speciality
Code
Description
License number
State
313M00000X
Nursing Facility/Intermediate Care Facility
Primary
113559
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
001012189
—
TX
01
—
HH320S
BLUE CROSS BLUE SHIELD
TX
Enumeration date
09/30/2005
Last updated
06/16/2008
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