UPI (Provider ID): 1043
Change Report (if Any):

Short Name: UMADAOP-DAYTON

Long Name 1: BLACK URBAN MINORITY ALCOHOL
Long Name 2: DRUG ABUSE OUTREACH PROGRAM

Address 1: 1 ELIZABETH PLACE
Address 2: 4 WEST PAVILION SUITE 400

City: DAYTON
Zip Code: 45408
County: MONT

Contact: DEBORAH STYLES
Title: EX DR
Phone: 9372762176
FAX: 9372762048

Vendor: 1043

Reports Status: CLAIMS/NO

MACSIS Last Update Date: 01/19/2012

File Produced: 19MAY2012