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Name: _______________________________________________________________________________
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Corporate/foundation
name if different: ___________________________________________________
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ADDRESS:
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Physical location
(street, city, state, zip)
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Mailing Address
(if different)
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_______________________________________
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_______________________________________
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_______________________________________
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_______________________________________
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_______________________________________
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_______________________________________
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Area code and
TELEPHONE NUMBER:
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Area code and
FACSIMILE NUMBER:
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_______________________________________
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_______________________________________
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TAX ID NUMBER:
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National Provider
Identifier (NPI) #
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_______________________________________
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_______________________________________
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Are you a MEDICARE
provider:
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( ) Yes
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( ) No
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If yes: Medicare
certification number:
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_______________________________________
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Medicare Category:
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_______________________________________
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Medicare acceptance
date:
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_______________________________________
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Are you JC
accredited?
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( ) Yes
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( ) No
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If yes: JC
classification:
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_______________________________________
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JC
classification
dates:
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FROM: _____________
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TO: ________________
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State License
classification:
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_______________________________________
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State License
dates:
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FROM: _____________
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TO: ________________
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Are you certified
by a national board?
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( ) Yes
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( ) No
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If yes:
Name of National board:
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_______________________________________
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Effective date
of certification:
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_______________________________________
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