UPI (Provider ID): 10095
Change Report (if Any):

Short Name: CSN-CHILD PROG

Long Name 1: CHILD AND ADOLESCENT
Long Name 2: ALTERNATIVE PROGRAM

Address 1: 200 LOVELESS STREET RM V101
Address 2: WESTERN RESERVE JR HIGH SCHOOL

City: WARREN
Zip Code: 44485
County: TRUM

Contact: ROCKY KURCHAK
Title: DIR
Phone: 3303927017
FAX: 3303928452

Vendor: 3275

Reports Status: NO CLAIMS/

MACSIS Last Update Date: 11/29/2011

File Produced: 14JUL2016