John    Tucker    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005160
NPI
1700927464
Tax ID
593182595
Effective Date
4/1/2012
Last Updated
10/2/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
68.00
Location Details
Address
202 Allamanda Drive
Lakeland, FL 33803
United States
County
Polk
Phone
9516891362 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address