Gary    Upchurch    OD
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005202
NPI
1720190101
Tax ID
351844966
Effective Date
4/1/2012
Last Updated
10/10/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
127 Foothills Avenue Suite 3
Albany, KY 42602
United States
County
Clinton
Phone
6063875612 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Optometry
Map
Address