UPI (Provider ID): 1074
Change Report (if Any):

Short Name: FRESH - CEDAR

Long Name 1: FRESH START I
Long Name 2:

Address 1: 4807 CEDAR AVENUE
Address 2:

City: CLEVELAND
Zip Code: 44103
County: CUYA

Contact: RUBY BLACK
Title: CFO
Phone: 2164312554
FAX: 2164314878

Vendor: 6955

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 06/28/2012

File Produced: 14JUL2016