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Get MI BHCS-LTC-101 2013-2024

Ng Officer Approval Date Approved Note: Failure to correctly complete this application in its entirety may delay the processing of your application. Questions regarding this application can be directed to the Long Term Care Division at (517) 241-4712. Choose one: Initial License Application Renewal Application Change of Ownership (CHOW) License Facility Information Facility Name/D.B.A. (Doing Business As) Address State Facility Number CMS Certification (CCN) # 23County Zip Code City Phon.

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