Terry Alan    Bunker    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004295
NPI
1336109859
Tax ID
752341407
Effective Date
4/1/2012
Last Updated
11/1/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
5407 New Copeland Road
Tyler, TX 75703
United States
County
Smith
Phone
9035973386 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address