Fred    Grayson    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004964
NPI
1629068812
Tax ID
591877068
Effective Date
4/1/2012
Last Updated
10/1/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
68.00
Location Details
Address
6800 West Commercial Boulevard Suite 4
Fort Lauderdale, FL 33319
United States
County
Broward
Phone
9547417000 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address