Contract Details
Ancillary Care Services
Facility name
Sports Back and Pain Management Clinic
Provider ID
P000004188
NPI
1275786469
Tax ID
263538393
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
2011 East Villa Maria Road Suite A
Bryan, TX 77802
United States
County
Brazos
Phone
9797762225 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Rehabilitation Facility
Map
Address