MACSIS Provider (PROVF) Summary Sheet

UPI (Provider ID): 10019
Change Report (if Any):

Short Name: TV NEW DIMN CSN

Long Name 1: TV NEW DIMENSIONS CSN
Long Name 2:

Address 1: 2611 WAYNE AVENUE BLDG 66
Address 2:

City: DAYTON
Zip Code: 45420
County: MONT

Contact: GREG WIGHTMAN
Title: EXDIR
Phone: 9372580440
FAX: .

Vendor: 3275

Reports Status: NO CLAIMS/

MACSIS Last Update Date: 11/29/2011

File Produced: 14JUL2016