Lauren    Roe    SLP
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004668
NPI
1487889671
Tax ID
264204210
Effective Date
4/1/2012
Last Updated
10/28/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
7500 North Beach Street
Fort Worth, TX 76137
United States
County
Tarrant
Phone
8175146333 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Speech Pathology
Map
Address