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Get Application For Change Of Nursing Facility Administrator Form Texas

R Administrator for Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions 1. Facility Name 2. Facility ID No. 3. Effective Date of Change 4. Physical Address (Street, City, State, ZIP) 5. County 6. Facility Telephone No. 7. Facility FAX No. ( ( ) 9. Name of New Administrator (Mr., Ms., Dr.) First Name 8. Facility Internet Address ) 10. Social Security No. MI Last Name 11. Administrator License No. Expiration Date (attach current renew.

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