UPI (Provider ID): 10036
Change Report (if Any):

Short Name: CHILD ADVANTAGE

Long Name 1: CHILDRENS ADVANTAGE
Long Name 2:

Address 1: 520 NORTH CHESTNUT STREET
Address 2:

City: RAVENNA
Zip Code: 44266
County: PORT

Contact: BARBARA CLARK
Title: EXDIR
Phone: 3302965552
FAX: 3302966126

Vendor: 10036

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 04/03/2012

File Produced: 19MAY2012