Cecil    Anderson    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004825
NPI
1568412369
Tax ID
582028984
Effective Date
4/1/2012
Last Updated
9/30/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
487 Winn Way Suite 201
Decatur, GA 30030
United States
County
DeKalb
Phone
4042979315 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address