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Get IA DHS 470-5111 2013-2024

Git Social Security Number for the individual entered in box 2. 6. Enter the date of birth for the individual entered in box 2. 7. Enter the primary service location, phone number, fax number. 8. Enter mailing address only if different than address in box 7. 9. Enter the Drug Enforcement Agency (DEA) number. If the provider does not have a DEA number, enter N/A. 10. Check the Yes box and attach an explanation if there has ever been disciplinary action against this provider’s license by a licen.

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