Provider Demographics
NPI:1598752495
Name:LEGACY LIVING CENTERS
Entity Type:Organization
Organization Name:LEGACY LIVING CENTERS
Other - Org Name:FORT WORTH MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-531-3707
Mailing Address - Street 1:4900 E BERRY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76105-4314
Mailing Address - Country:US
Mailing Address - Phone:817-531-3707
Mailing Address - Fax:817-536-1648
Practice Address - Street 1:4900 E BERRY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76105-4314
Practice Address - Country:US
Practice Address - Phone:817-531-3707
Practice Address - Fax:817-536-1648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113559314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675191Medicare ID - Type Unspecified