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Printed: 09/20/2024 Form Approved OMB No. 09380391Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA

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The 2701 Mitchell Street Box is a specific form or document used for reporting certain information related to a specific regulatory or tax requirement, though specific details may vary based on the jurisdiction and context.

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Individuals or organizations that meet particular criteria set forth by the governing body or regulatory authority overseeing the 2701 Mitchell Street requirements are required to file this document.

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The information required on the 2701 Mitchell Street Box usually includes identification details, financial data, compliance-related information, and any other specific items outlined by the filing instructions.