Fortino    Gonzalez    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005356
NPI
1790798932
Tax ID
742559987
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
4900 North 10th Street Suite D-2
McAllen, TX 78504
United States
County
Hidalgo
Phone
9566826778 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address