Dixon    Golden    OD
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004830
NPI
1568468585
Tax ID
751789322
Effective Date
4/1/2012
Last Updated
10/31/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
702 Louisiana Street
Center, TX 75935
United States
County
Shelby
Phone
9365988501 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Optometry
Map
Address