John    Kostidis    DC
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005656
NPI
1932381746
Tax ID
351449483
Effective Date
4/1/2012
Last Updated
10/21/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
76.00
Location Details
Address
4004 Campbell Street
Valparaiso, IN 46385
United States
County
Porter
Phone
2194651140 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Chiropractic Medicine
Map
Address