Sylvia    Olivares    SLP
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005673
NPI
1942398151
Tax ID
421659321
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
505 Highway 100
Laguna Heights, TX 78578
United States
County
Cameron
Phone
9569439600 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Speech Pathology
Map
Address