UPI (Provider ID): 1323
Change Report (if Any):

Short Name: SPENCER HOUSE

Long Name 1: SPENCER HALF WAY HOUSE
Long Name 2:

Address 1: 69 GRANVILLE STREET
Address 2: PO BOX 4005

City: NEWARK
Zip Code: 430584005
County: LICK

Contact: KEN BILLIG
Title: CQI
Phone: 7403457030
FAX: 7403457454

Vendor: 1323

Reports Status: NO CLAIMS/

MACSIS Last Update Date: 11/29/2011

File Produced: 19MAY2012