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PRINTED: 07/20/2012 FORM APPROVED Health Red action & Licensing Ad ministration STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xi) PROVIDER/SUPPLIERICLIA IDENTIFICATION NUMBER ALR 0027 NAME OF
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Name of provider refers to the individual or company providing a service or product.
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Any individual or company who is providing a service or product must file the name of provider.
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The purpose of the name of provider is to identify who is responsible for providing the service or product.
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The information that must be reported on the name of provider includes the legal name and contact information of the individual or company providing the service or product.
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