Provider Demographics
NPI:1447246145
Name:KILGORE MANOR INC
Entity Type:Organization
Organization Name:KILGORE 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 1:2700 S HENDERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-4033
Mailing Address - Country:US
Mailing Address - Phone:903-984-3511
Mailing Address - Fax:903-983-1031
Practice Address - Street 1:2700 S HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-4033
Practice Address - Country:US
Practice Address - Phone:903-984-3511
Practice Address - Fax:903-983-1031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112798313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00102185Medicaid
TXHH2539OtherBLUE CROSS BLUE SHIELD
TX0220162-01OtherTEXAS MEDICAID B
TX00102185Medicaid