John    Petty    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005432
NPI
1821121872
Tax ID
751722871
Effective Date
4/1/2012
Last Updated
10/31/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
88.00
Location Details
Address
452 Forest Square
Longview, TX 75605
United States
County
Gregg
Phone
9037573400 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address