UPI (Provider ID): 6761
Change Report (if Any):

Short Name: TALBOT HS-CLARK

Long Name 1: MATT TALBOT HOUSE
Long Name 2:

Address 1: 809 SOUTH LIMESTONE STREET
Address 2:

City: SPRINGFIELD
Zip Code: 45505
County: CLAR

Contact: LARRY COX
Title: ED
Phone: 9373220872
FAX: 9373225820

Vendor: 6761

Reports Status: CLAIMS/NO

MACSIS Last Update Date: 11/29/2011

File Produced: 19MAY2012