James    Victory    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005538
NPI
1881781631
Tax ID
640931880
Effective Date
4/1/2012
Last Updated
9/30/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
315 Highway 90
Gautier, MS 39553
United States
County
Jackson
Phone
2284979907 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address