UPI (Provider ID): 6373
Change Report (if Any):

Short Name: SETT

Long Name 1: SELF EXPRESSION TEEN THEATER
Long Name 2:

Address 1: 1001 INDIANA AVENUE SUITE 203
Address 2:

City: TOLEDO
Zip Code: 43607
County: LUCA

Contact: CHARLES MUHAMMAD
Title: EX DR
Phone: 4192422255
FAX: 4192423152

Vendor: 6373

Reports Status: CLAIMS/NO

MACSIS Last Update Date: 11/29/2011

File Produced: 19MAY2012