Eric    Sutherland    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005097
NPI
1689730319
Tax ID
208052037
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
3328 Bemiss Road
Valdosta, GA 31605
United States
County
Lowndes
Phone
2292441201 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address