UPI (Provider ID): 12923
Change Report (if Any):

Short Name: DECLARE

Long Name 1: DECLARE THERAPY CENTER
Long Name 2:

Address 1: 700 WEST PETE ROSE WAY
Address 2:

City: CINCINNATI
Zip Code: 45203
County: HAMI

Contact: PURCELL TAYLOR
Title: EXDIR
Phone: 5138347050
FAX: 5138347052

Vendor: 12923

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 12/30/2011

File Produced: 19MAY2012