Perry    Lyons    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004251
NPI
1316142094
Tax ID
351873749
Effective Date
4/1/2012
Last Updated
10/21/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
5649 Coventry Lane
Fort Wayne, IN 46804
United States
County
Allen
Phone
2604366565 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address