UPI (Provider ID): 5005
Change Report (if Any):

Short Name: UMADAOP-MANSFLD

Long Name 1: MANSFIELD URBAN MINORITY ALCOH
Long Name 2: AND DRUG ABUSE OUTREACH PROG

Address 1: 400 BOWMAN STREET
Address 2: PO BOX 1316

City: MANSFIELD
Zip Code: 44901
County: RICH

Contact: GERON TATE
Title: DIR
Phone: 4195253525
FAX: 4195253532

Vendor: 5005

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 12/20/2011

File Produced: 19MAY2012