Contract Details
Ancillary Care Services
Facility name
Active Health & Wellness Center
Provider ID
P000004521
NPI
1427179787
Tax ID
351992378
Effective Date
4/1/2012
Last Updated
10/21/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
3027 Mishawaka Avenue
South Bend, IN 46615
United States
County
St Joseph
Phone
5742599355 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address