UPI (Provider ID): 1316
Change Report (if Any):

Short Name: AOD CENTER-LAKE

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

Address 1: 9083 MENTOR AVENUE
Address 2:

City: MENTOR
Zip Code: 44060
County: LAKE

Contact: ANTHONY KUHN
Title: EX DR
Phone: 4409513511
FAX: 4402556348

Vendor: 1316

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 12/13/2011

File Produced: 19MAY2012