Healthcare Provider Details

I. General information

NPI: 1114924529
Provider Name (Legal Business Name): LEGACY CARE CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 W CANNON ST
FORT WORTH TX
76104-3026
US

IV. Provider business mailing address

3801 WOODSIDE DR
ARLINGTON TX
76016-3030
US

V. Phone/Fax

Practice location:
  • Phone: 817-332-9261
  • Fax: 817-332-3035
Mailing address:
  • Phone: 817-654-3042
  • Fax: 817-446-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number112967
License Number StateTX

VIII. Authorized Official

Name: MS. CHERYL L KILLIAN
Title or Position: PRESIDENT
Credential:
Phone: 817-654-3042