MACSIS Provider (PROVF) Summary Sheet

UPI (Provider ID): 11138
Change Report (if Any):

Short Name: MINORITY OUTRCH

Long Name 1: MADISON AREA YOUTH CENTER
Long Name 2: MINORITY OUTREACH

Address 1: 15 EAST SECOND STREET
Address 2:

City: LONDON
Zip Code: 43140
County: MADI

Contact: TY ARTIS
Title: COORD
Phone: 7408521595
FAX: 7408520914

Vendor: 11139

Reports Status: NO CLAIMS/

MACSIS Last Update Date: 11/29/2011

File Produced: 19MAY2012