Cassandra Lynn    Larue - Headon    DC
Contract Details
Facility name
Provider ID
P000004402
NPI
1386715423
Tax ID
201429503
Effective Date
4/1/2012
Last Updated
10/23/2012
Direct Contract
Yes
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
1212 Currency Ct
Rochelle, IL 61068
United States
County
Ogle
Phone
8155618500 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address