Contract Details
Ancillary Care Services
Facility name
Custom Healthcare
Provider ID
P000004705
NPI
1508879529
Tax ID
721310729
Effective Date
4/1/2012
Last Updated
10/31/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
9407 College Street
Beaumont, TX 77707
United States
County
Jefferson
Phone
4098326060 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Rehabilitation Facility
Map
Address