Lili    Gipson    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004716
NPI
1518068089
Tax ID
264633185
Effective Date
4/1/2012
Last Updated
9/27/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
88.00
Location Details
Address
715 Bascomb Commercial Parkway Suite A
Woodstock, GA 30189
United States
County
Cherokee
Phone
7709249400 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address