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QA 6/13/17 JL LABORATORY DIRECTOR S OR PROVIDER/SUPPLIER REPRESENTATIVE S SIGNATURE STATE FORM TITLE ZBYZ11 X6 DATE If continuation sheet 1 of 1. PRINTED 06/19/2017 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION X1 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER IU HEALTH WEST HOSPITAL X4 ID PREFIX TAG A. BUILDING X3 DATE SURVEY COMPLETED B. WING 003776 NAME OF PROVIDER OR SUPPLIER X2 MULTIPLE CONSTRUCTION 04/07/2017 STREET ADDRESS CITY STATE...
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