Contract Details
Ancillary Care Services
Facility name
Healthsource of Southlake
Provider ID
P000004415
NPI
1396025151
Tax ID
452691249
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
2225 West Southlake Boulevard Suite 441
Southlake, TX 76092
United States
County
Tarrant
Phone
8173100150 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address