Jayson    Cannon    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004900
NPI
1598763278
Tax ID
261582065
Effective Date
4/1/2012
Last Updated
9/26/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
76 Tabb Drive Suite C
Munford, TN 38058
United States
County
Tipton
Phone
9018402234 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address