MACSIS Provider (PROVF) Summary Sheet

UPI (Provider ID): 10420
Change Report (if Any):

Short Name: BRIDGEWAY-VALLE

Long Name 1: BRIDGEWAY INC
Long Name 2:

Address 1: 4216 VALLEY ROAD
Address 2:

City: OLD BROOKLYN
Zip Code: 44109
County: CUYA

Contact: GENISE HERBERT
Title:
Phone: 2163985203
FAX: .

Vendor: 10509

Reports Status: NO CLAIMS/

MACSIS Last Update Date: 11/29/2011

File Produced: 14JUL2016