UPI (Provider ID): 1505
Change Report (if Any):

Short Name: IBH AOD REHAB

Long Name 1: INTERVAL BROTHERHOOD HOME
Long Name 2:

Address 1: 3445 SOUTH MAIN STREET
Address 2:

City: AKRON
Zip Code: 44319
County: SUMM

Contact: FATHER SAM CICCOLINI
Title:
Phone: 3306444095
FAX: 3306452031

Vendor: 1505

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 11/29/2011

File Produced: 14JUL2016