Basic Information
| Provider Information | |||||||||
| NPI: | 1982691226 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VIDOR MANOR NURSING HOME INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | LEGACY LIVING CENTERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 470 MOORE DR | ||||||||
| Address2: | |||||||||
| City: | VIDOR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776623843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097692454 | ||||||||
| FaxNumber: | 4097699324 | ||||||||
| Practice Location | |||||||||
| Address1: | 470 MOORE DR | ||||||||
| Address2: | |||||||||
| City: | VIDOR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776623843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097692454 | ||||||||
| FaxNumber: | 4097699324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PITA | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE/MEDICARE | ||||||||
| AuthorizedOfficialTelephone: | 5806226300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 114895 | TX | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 001013574 | 05 | TX | MEDICAID |