subject_line
Company Name ( or proposed name)
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Corporate Address
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Additional Site Address(es) (type "none" if you don't have any)
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Primary Contact Name
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Primary Contact Telephone #
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Primary Contact e-mail
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Type of Company-Type S, Type C, LLC etc (type "TBD" if you don't have one yet)
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Type of Company
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For Profit
Non Profit
NPI (type "TBD" if you don't have one yet)
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TIN/EIN (type "TBD" if you don't have one yet)
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Website
What services do you want to provide? Where?
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What services do you currently provide? Where? (type none, if you don't have any yet)
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Nationally accredited? If you are, please check the AO. If not, and you need to be please check "need to be" and the AO of choice.
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Not needed
Need to be
CARF
TJC
ACHC
COA
Expiration date
Expiration date