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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 155510

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1. Start by writing your full name in the "Full Name" section of the form.
2. Next, provide your complete address in the "Address" field. In this case, enter "705 N Meridian St".
3. Specify your city, state, and zip code in the corresponding fields. If you are filling out a physical form, make sure to write the city, state, and zip code for the location of 705 N Meridian St.
4. If applicable, provide any additional information requested on the form, such as your email address, phone number, or social security number.
5. Carefully review the completed form to ensure accuracy and correctness.
6. Finally, sign and date the form, indicating your agreement and confirmation.

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705 N Meridian St is the address of a specific location.

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