Contract Details
Ancillary Care Services
Facility name
Russellville Orthotics & Prosthetics
Provider ID
P000004037
NPI
1215932801
Tax ID
621504832
Effective Date
4/1/2012
Last Updated
10/10/2013
Direct Contract
No
Status
Active
Contract Discounts
Discount Type
S
State Fee Schedule Multiplier
68.00
Location Details
Address
230 South Franklin Street
Russellville, KY 42276
United States
County
Logan
Phone
2707261200 (Phone)
Billing Details
Address
5429 LBJ Freeway
Suite 700
Dallas, TX 75240
Specialty Type
Orthotics/Prosthetics, Services
Map
Address