Facility Role

42607

Agency Interest ID

16999

Facility ID

Closed

Facility Status

Jim Russell

Facility Contact

Role

Entity Type

Ownership Type

Ownership Type Other

Effective Date

Proposed End Date (MM/DD/YYYY)

Business/Public Agency/Other Entity

Can't Find Business

Business Name

Business ID (From the Secretary of State)

Owner Entity Number

Individual Name

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Prefix

Owner Entity Number

First Name

OSFM ID

Job Title

Last Name

Suffix

Business Name/Individual Name

Peoplesoft Customer ID

Telephone Number

Address

I have met the financial responsibility requirements (in accordance with 329 IAC 9-8)

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