Gary    Upchurch    OD
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004004
NPI
1205065463
Tax ID
351844966
Effective Date
4/1/2012
Last Updated
9/27/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
2945 Maynardville Highway Suite 6
Maynardville, TN 37807
United States
County
Union
Phone
8659928899 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Optometry
Map
Address