UPI (Provider ID): 1052
Change Report (if Any):

Short Name: FAM REC-LISBON

Long Name 1: FAMILY RECOVERY CENTER
Long Name 2:

Address 1: 964 NORTH MARKET STREET
Address 2: PO BOX 464

City: LISBON
Zip Code: 44432
County: COLU

Contact: MILLIE BURTON
Title: AC MG
Phone: 3304241468
FAX: 3304249844

Vendor: 1052

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 12/08/2011

File Produced: 19MAY2012