Get the free NAME OF PROVIDER OR SUPPLIER STREET ADDRESS ... - NC DHHS
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PRINTED: 09×11/2020 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION×X1) PROVIDER×SUPPLIER×CIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION
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Start by writing your first name followed by your last name.
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What is name of provider or?
Name of provider refers to the individual or entity who is providing a service or product.
Who is required to file name of provider or?
The person or company providing the service or product is required to file the name of provider.
How to fill out name of provider or?
Name of provider can be filled out by providing the legal name or business name of the individual or entity.
What is the purpose of name of provider or?
The purpose of name of provider is to identify the source of a service or product.
What information must be reported on name of provider or?
The information required to be reported on name of provider includes the legal name or business name of the provider.
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