UPI (Provider ID): 10015
Change Report (if Any):

Short Name: LIFE ESSENTIALS

Long Name 1: LIFE ESSENTIALS
Long Name 2:

Address 1: 123 RIVERSIDE DRIVE SUITE 100
Address 2:

City: DAYTON
Zip Code: 45405
County: MONT

Contact: KATHY DIERKER
Title: EXDIR
Phone: 9375860545
FAX: 9375860565

Vendor: 10015

Reports Status: CLAIMS/NO

MACSIS Last Update Date: 11/29/2011

File Produced: 19MAY2012