Contract Details
Ancillary Care Services
Facility name
Diabetic Support Program
Provider ID
P000004980
NPI
1639126352
Tax ID
650155071
Effective Date
4/1/2012
Last Updated
10/2/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
68.00
Location Details
Address
3381 Fairlane Farms Road Suite 1-A
Wellington, FL 33414
United States
County
Palm Beach
Phone
5617959806 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Durable Medical Equipment & Medical Supplies
Map
Address