John    Desimio    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005046
NPI
1669457842
Tax ID
742931326
Effective Date
4/1/2012
Last Updated
10/31/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
3120 Highway 36 South
Brenham, TX 77833
United States
County
Washington
Phone
9792779186 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address