Contract Details
Ancillary Care Services
Facility name
MediWell
Provider ID
P000004748
NPI
1538142542
Tax ID
752421301
Effective Date
4/1/2012
Last Updated
11/1/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
5354 West Vickery Boulevard
Fort Worth, TX 76107
United States
County
Tarrant
Phone
8177354210 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Durable Medical Equipment & Medical Supplies
Map
Address