MACSIS Provider (PROVF) Summary Sheet

UPI (Provider ID): 2293
Change Report (if Any):

Short Name: EVE-WASH

Long Name 1: EVE INC
Long Name 2:

Address 1: PO BOX 122
Address 2:

City: MARIETTA
Zip Code: 45750
County: WASH

Contact: MICHELLE TORNES
Title: FISC
Phone: 7403745819
FAX: 7403735321

Vendor: 2293

Reports Status: CLAIMS/NO

MACSIS Last Update Date: 11/29/2011

File Produced: 19MAY2012