H. Lee    Black    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005733
NPI
1972538346
Tax ID
752258848
Effective Date
4/1/2012
Last Updated
11/1/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
68.00
Location Details
Address
389 Wildwood Court
Mansfield, TX 76063
United States
County
Tarrant
Phone
8174736151 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address