Provider Demographics
NPI:1124015268
Name:KENEDY MANOR NURSING HOME INC
Entity Type:Organization
Organization Name:KENEDY MANOR NURSING HOME INC
Other - Org Name:LEGACY LIVING CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE/MEDICARE
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:PITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-622-6300
Mailing Address - Street 1:7882 S HIGHWAY 181
Mailing Address - Street 2:DRAWER E
Mailing Address - City:KENEDY
Mailing Address - State:TX
Mailing Address - Zip Code:78119-0930
Mailing Address - Country:US
Mailing Address - Phone:830-583-9101
Mailing Address - Fax:830-583-2962
Practice Address - Street 1:7882 S HIGHWAY 181
Practice Address - Street 2:DRAWER E
Practice Address - City:KENEDY
Practice Address - State:TX
Practice Address - Zip Code:78119
Practice Address - Country:US
Practice Address - Phone:830-583-9101
Practice Address - Fax:830-583-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115272313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility