Contract Details
Ancillary Care Services
Facility name
Southwest Back Clinic
Provider ID
P000004297
NPI
1336157569
Tax ID
481274559
Effective Date
4/1/2012
Last Updated
10/28/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
84.00
Location Details
Address
4241 Southwest Boulevard Suite 106
San Angelo, TX 76904
United States
County
Tom Green
Phone
3259472225 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address