Sandra    De Sousa    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000004987
NPI
1639239056
Tax ID
270074433
Effective Date
4/1/2012
Last Updated
9/27/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
4327 Mundy Mill Road Suite A, Building One
Oakwood, GA 30566
United States
County
Hall
Phone
7705322273 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address