Mini    John    OD
Contract Details
Facility name
Provider ID
P000004032
NPI
1215902200
Tax ID
760314636
Effective Date
4/1/2012
Last Updated
10/23/2012
Direct Contract
Yes
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
821 East Southmore
Pasadena, TX 77502
United States
County
Harris
Phone
7134732020 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Optometry
Map
Address