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PRINTED: 06/17/2021
FORM APPROVEDDivision of Health Service Regulation
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA
IDENTIFICATION NUMBER:CYNTHIA\'S HEART
(X4) ID
PREFIX
TAG.
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The printed 0617 form approved is a specific tax form used for reporting certain financial information to the relevant tax authorities.
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