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Rate name 202 d. Other, please explain 2. a. Legal name as reported to IRS or Social Security Administration b. Facility name 1. 202 Facility address (number and street) Telephone number 246 4. Federal employer s tax ID number (FEIN) 212 5. Fiscal year 216 or Social Security number issued to name in Item 1.a. City 3. County State Pay to address (if different number and street) City County 203 ZIP code Telephone number State ZIP code end month 6.a. Type of organizat.

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