UPI (Provider ID): 1318
Change Report (if Any):

Short Name: CROSSROADS-LAKE

Long Name 1: CROSSROADS LAKE COUNTY
Long Name 2: ADOLESCENT COUNSELING SERVICE

Address 1: 8445 MUNSON ROAD
Address 2:

City: MENTOR
Zip Code: 44060
County: LAKE

Contact: PEGGY KLEIN
Title:
Phone: 4402551700
FAX: 4402052417

Vendor: 1318

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 11/29/2011

File Produced: 19MAY2012