Forth Worth Manor Inc

Primary specialty

Nursing Facility/Intermediate Care FacilityTaxonomy code 313M00000X

License

113559 Issued in TX

Legal business name

FORTH WORTH MANOR INC

Practice address

110 W Muskogee Ave
Sulphur, OK 73086-4810

Phone

(580) 622-6300

Fax

(580) 622-8344

NPI assigned

Sep 30, 2005

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Janice Pita

Title

Insurance/Medicare

Phone

(580) 622-6300

Specialties & licenses 1

Addresses

Other identifiers 2

Other names 1

• Legacy Living Centers Doing business as

Tax ID family

Fort Worth Manor2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Legacy Living Centers

  • Skilled Nursing Facility
  • Fort Worth, TX
  • NPI 1598752495
  NPD tax ID

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1128038400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1213574400000",
    "number": "1891782298",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4900 E BERRY ST",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761054314",
            "telephone_number": "817-531-3707",
            "fax_number": "817-536-1648"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "110 W MUSKOGEE AVE",
            "city": "SULPHUR",
            "state": "OK",
            "postal_code": "730864810",
            "telephone_number": "580-622-6300",
            "fax_number": "580-622-8344"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORTH WORTH MANOR INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-09-30",
        "last_updated": "2008-06-16",
        "status": "A",
        "authorized_official_last_name": "PITA",
        "authorized_official_first_name": "JANICE",
        "authorized_official_title_or_position": "INSURANCE/MEDICARE",
        "authorized_official_telephone_number": "580-622-6300"
    },
    "taxonomies": [
        {
            "code": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": "TX",
            "license": "113559",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BLUE CROSS BLUE SHIELD",
            "identifier": "HH320S",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "001012189",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Legacy Living Centers",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Julia Diaz, APRN
• Rebecca Doty
• Joe Bill Dressler, M.D.
• Elbert a. Franklin, D.D.S.
• Leah Flowers
• Elbert A. Franklin, D.D.S.
• Mindee Freeman
• Tyger Michelle Freeman
• Lindsay Gaylor
• Bobbye Carol Gowan, B.S., PHARMD, CDM

• Nursing Facility/Intermediate Care Facility in Sulphur, OK
• Providers in Sulphur, OK by specialty
• Nursing Facility/Intermediate Care Facility in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.