Kevin    Musliwiec    OD
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004167
NPI
1275539736
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
2523 Jacksboro Pike
Jacksboro, TN 37757
United States
County
Campbell
Phone
4235662020 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Optometry
Map
Address