Get LA Standardized Credentialing Application 2008
_____________________________________ _______________________________________________________________________________ _______________________________________________________________________________ THIRD PRACTICE LOCATION INSTITUTION/GROUP/CLINIC NAME (If applicable) OFFICE MANAGER STREET ADDRESS CITY PHONE NUMBER FAX NUMBER TYPE OF PRACTICE: SOLO STATE ZIP CODE OFFICE E-MAIL MULTISPECIALTY GROUP TAX IDENTIFICATION NUMBER/ DATE TAX ID # EFFECTIVE - PROVIDER SINGLE SPECIALTY GROUP .
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