UPI (Provider ID): 1492
Change Report (if Any):

Short Name: CRISIS CENTER

Long Name 1: CRISIS INTERVENTION AND
Long Name 2: RECOVERY CENTER

Address 1: 2421 13TH STREET NW
Address 2:

City: CANTON
Zip Code: 44708
County: STAR

Contact: BERNARD JESIOLOWSKI
Title: EX DR
Phone: 3304529812
FAX: 3304544357

Vendor: 1492

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 12/27/2011

File Produced: 19MAY2012