Charles    Keith    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004143
NPI
1265472369
Tax ID
752304952
Effective Date
4/1/2012
Last Updated
11/1/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
88.00
Location Details
Address
316 South Goliad Street Suite 111
Rockwall, TX 75087
United States
County
Rockwall
Phone
9727719448 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address