Contract Details
Ancillary Care Services
Facility name
Lady Like Mastectomy Boutique
Provider ID
P000003971
NPI
1184669707
Tax ID
651280541
Effective Date
4/1/2012
Last Updated
10/31/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
84.00
Location Details
Address
4823 Fredericksburg Road
San Antonio, TX 78229
United States
County
Bexar
Phone
2106551300 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Durable Medical Equipment & Medical Supplies
Map
Address