UPI (Provider ID): 1322
Change Report (if Any):

Short Name: ALC PREV-LICK

Long Name 1: LICKING COUNTY ALCOHOLISM
Long Name 2: PREVENTION PROGRAM

Address 1: 62 EAST STEVENS STREET
Address 2:

City: NEWARK
Zip Code: 43055
County: LICK

Contact: BOB FORSYTHE
Title: CFO
Phone: 7403667303
FAX: 7403667305

Vendor: 1322

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 12/14/2011

File Produced: 19MAY2012