UPI (Provider ID): 3570
Change Report (if Any):

Short Name: CHILD/ADOL SERV

Long Name 1: CHILD AND ADOLESCENT
Long Name 2: BEHAVIORAL HEALTH

Address 1: 919 SECOND STREET NE
Address 2:

City: CANTON
Zip Code: 447041132
County: STAR

Contact: LILLIAN BLOSFIELD
Title: CFO
Phone: 3304547917
FAX: 3304541476

Vendor: 3570

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 12/06/2011

File Produced: 19MAY2012