Monty    Banks    OD
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004609
NPI
1467504639
Tax ID
752621249
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
101 North Dale Avenue
Stephenville, TX 76401
United States
County
Erath
Phone
2549684133 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Optometry
Map
Address