Robert Steve    Allen    RPT
Contract Details
Ancillary Care Services
Facility name
Provider ID
P000005812
NPI
1407819709
Tax ID
582318559
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
300 Sunset Circle
Moultrie, GA 31768
United States
County
Colquitt
Phone
2299852080 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Physical Therapy
Map
Address