UPI (Provider ID): 6782
Change Report (if Any):

Short Name: COVENANT-CUYA

Long Name 1: COVENANT ADOLESCENT CD
Long Name 2: TREATMENT PREVENTION CENTER

Address 1: 1515 WEST 29TH STREET
Address 2:

City: CLEVELAND
Zip Code: 44113
County: CUYA

Contact: RICHARD PIAZZA
Title: PROGD
Phone: 2165749000
FAX: 2166646534

Vendor: 6782

Reports Status: CLAIMS/BH

MACSIS Last Update Date: 09/24/2013

File Produced: 14JUL2016