Jayne    Kwiatkowski    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004056
NPI
1225112048
Tax ID
550809108
Effective Date
4/1/2012
Last Updated
10/1/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
1081 W.P Ball Boulevard
Sanford, FL 32771
United States
County
Seminole
Phone
4073287595 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address