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PRINTED: 05/18/2021
FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
(X1)STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION OMB NO 09380391
(X2) MULTIPLEPROVIDER/SUPPLIER/CIA
IDENTIFICATION
NUMBER:A.
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Start with your full name.
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Write the name of the street or avenue.
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Provide the postal code for accurate delivery.
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What is street address?
Street address is the specific address of a particular location on a street.
Who is required to file street address?
Anyone who resides or conducts business at a specific location on a street is required to file their street address.
How to fill out street address?
One can fill out their street address by including the building or house number, street name, city, state, and postal code.
What is the purpose of street address?
The purpose of street address is to accurately locate a particular individual or business at a specific location.
What information must be reported on street address?
The information that must be reported on a street address includes the building or house number, street name, city, state, and postal code.
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