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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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