Contract Details
Facility name
East Texas Performance Rehabilitation Inc
Provider ID
P000004017
NPI
1205928561
Tax ID
752849130
Effective Date
4/1/2012
Last Updated
10/23/2012
Direct Contract
Yes
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
2220 Hg Mosley Pkwy Suite 100
Longview, TX 75604
United States
County
Gregg
Phone
9032473422 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Rehabilitation Facility
Map
Address