UPI (Provider ID): 12451
Change Report (if Any):

Short Name: PHOENIX RISING

Long Name 1: PHOENIX RISING BEHAVIORAL
Long Name 2: HEALTH CARE AND RECOVERY INC

Address 1: 1930 FREMONT PLACE SW
Address 2:

City: CANTON
Zip Code: 44706
County: STAR

Contact: KELLY BENNINGTON
Title:
Phone: 3304559100
FAX: 3304554702

Vendor: 12451

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 12/22/2011

File Produced: 19MAY2012