Provider Demographics
NPI:1891782298
Name:FORTH WORTH MANOR INC
Entity Type:Organization
Organization Name:FORTH WORTH MANOR 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 1:4900 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 1:110 W MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:OK
Practice Address - Zip Code:73086-4810
Practice Address - Country:US
Practice Address - Phone:580-622-6300
Practice Address - Fax:580-622-8344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113559313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXHH320SOtherBLUE CROSS BLUE SHIELD
TX001012189Medicaid
TX67-5191Medicare ID - Type UnspecifiedMEDICARE TEXAS