Provider Demographics
NPI:1346236056
Name:VIDOR MANOR INC
Entity Type:Organization
Organization Name:VIDOR MANOR INC
Other - Org Name:LEGACY LIVING CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE/MEDICARE
Authorized Official - Prefix:MRS
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 1:545 S DENVER ST
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-5009
Mailing Address - Country:US
Mailing Address - Phone:409-769-4542
Mailing Address - Fax:409-769-8212
Practice Address - Street 1:545 S DENVER ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-5009
Practice Address - Country:US
Practice Address - Phone:409-769-4542
Practice Address - Fax:409-769-8212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113626313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid
TX=========Medicaid