Mark    Hanson    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005220
NPI
1730189903
Tax ID
260348590
Effective Date
4/1/2012
Last Updated
10/23/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
1615 West Oleander Street Suite A
Fort Worth, TX 76104
United States
County
Tarrant
Phone
2146163355 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address