Jonathan    Conrad    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000006579
Tax ID
331141688
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
7148 Trail Lake Drive Suite B
Fort Worth, TX 76123
United States
County
Tarrant
Phone
8172979670 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address