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PRINTED: 09/12/2016
FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA
IDENTIFICATION
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Start by writing the recipient's name at the top of the address field
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Write the house number '2105' followed by 'Homestead Hills Drive' in the next line
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04
Write the city, state, and zip code on the final line of the address
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What is 2105 homestead hills drive?
2105 Homestead Hills Drive is a specific address/location.
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