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Contract Details
Southern Physical Rehab Network
Facility name
Provider ID
P000001662
NPI
1669479754
Tax ID
721379419
Effective Date
1/16/2004
Last Updated
6/9/2014
Direct Contract
Yes
Term Date
11/20/2013
Status
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
80.00
Location Details
Address
Lake Martin Physical Therapy 309 Mariarden Road
Dadeville, AL 36853
United States
County
Tallapoosa
Phone
2568252303 (Phone)
Billing Details
Address
109 9th Street Southwest
Suite C
Cullman, AL 35055
Billing Phone
2567369926
Specialty Type
Physical Therapy
Map
Address