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Provider Address Change FormProvider Name(please print)Provider ID Number/Taxonomy Nonphysical Address(Where services are provided)(Post office box allowed ONLY as an addition to a street address)City×State×ZIP+4County×Phone
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Where services are provided refers to the location or address where the services were rendered.
Individuals or businesses who provided services at a specific location are required to file where services are provided.
To fill out where services are provided, you need to indicate the address or location where the services were performed.
The purpose of where services are provided is to accurately record and report the location of services rendered for tax or billing purposes.
The information reported on where services are provided should include the address or location, date, and description of services rendered.
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