Tanaka    Taylor    OD
Contract Details
Southmore Texas State Optical
Facility name
Provider ID
P000004273
NPI
1326013798
Tax ID
760162354
Effective Date
4/1/2012
Last Updated
10/23/2012
Direct Contract
Yes
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
4400 North Fwy Suite B300
Houston, TX 77022
United States
County
Harris
Phone
7136972081 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Optometry
Map
Address