Clark Kevin    Cole    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005746
NPI
1972617306
Tax ID
204060709
Effective Date
4/1/2012
Last Updated
10/22/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
1005 Northeast Big Bend Trail Suite 3
Glen Rose, TX 76043
United States
County
Somervell
Phone
2548982121 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address