Ayam  T  De Leon    RPT
Contract Details
Facility name
Provider ID
P000005429
NPI
1821084385
Tax ID
203288160
Effective Date
4/1/2012
Last Updated
10/23/2012
Direct Contract
Yes
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
17243 Highland Ave Suite 5A
Jamaica, NY 11432
United States
County
Queens
Phone
7182914703 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address