UPI (Provider ID): 1225
Change Report (if Any):

Short Name: AOD CENTER-GEAU

Long Name 1: LAKE GEAUGA RECOVERY CENTERS
Long Name 2: INC

Address 1: 209 CENTER STREET UNIT E
Address 2:

City: CHARDON
Zip Code: 44024
County: GEAU

Contact: MELANIE BLASKO
Title: DIR
Phone: 4402859119
FAX: 4409420639

Vendor: 1316

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 12/12/2011

File Produced: 19MAY2012