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Name of Provider Agency: Please provide the name and contact information for person completing this form: Name: Telephone Number: Address: Email: Reporting Period:1st Quarter (July Sept.)2nd Quarter
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Name of provider agency refers to the official name of the agency providing services or goods.
The agency or organization that is providing services or goods is required to file the name of provider agency.
The name of provider agency can be filled out on the required forms provided by the relevant authority.
The purpose of name of provider agency is to identify the agency or organization providing services or goods.
The information reported on name of provider agency typically includes the full legal name of the agency or organization.
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