William    Dodson    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004222
NPI
1295853836
Tax ID
752617756
Effective Date
4/1/2012
Last Updated
11/1/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
701 North Grant Avenue
Odessa, TX 79761
United States
County
Ector
Phone
4325803300 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address