MEDICARE: LEGACY CARE CENTERS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	112967	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114924529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEGACY CARE CENTERS, INC.

Provider Business Mailing Address
First Line	:	3801 WOODSIDE DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016-3030
Country	:	US
Telephone Number	:	817-654-3042
Fax Number	:	817-446-3666

Provider Business Practice Location Address
First Line	:	921 W CANNON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3026
Country	:	US
Telephone Number	:	817-332-9261
Fax Number	:	817-332-3035

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. CHERYL L KILLIAN
Credential	:
Telephone Number	:	817-654-3042

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	08/22/2020

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