Laserfiche WebLink
? :3 s 3 T <br />Facil1ty <br />Appl1cat113Il <br />??. <br />CONF???TLAUPROPR.?TARY <br /> , -' <br /> This form should be typed or leab2y printed in black ar bhue ink. If more space is needeci than provided cxz rniginat <br />attaeh additionat sheets aud <br /> , <br />referenee the question being mswered CaprrenE copies of the following documenis MUST be sabmittec3 with thas appiication: <br /> • State License <br /> • CNf S Site visit HCFA 2567 (if agglicable) <br /> • Certifteation IetEec from Meciieaid (if appiicable) <br /> • Facility Accreditation Cert7ificate (s) <br /> • I.F3bF11ty COVef3ae F3CC ShEEt <br /> f O ' •' ' ; j INFOR?4TIOTNN <br /> Facility Name: <br /> 1l ! LLf?GE b ? ?4?/FiELl? <br />Federal Tax ID Number: t! <br />3- (oOG f F?? Faciliry Type: ?Yn8U L4 NG [= <br />DBA Name or LeDal Name: <br />Address: q,7 <br />CE/VTc R RDA Suite Number: <br />City: M 19 = I E L D 1 C L A Cs 6 County: u a U State: ZjP? .$/y / y 3 <br />Telephone Number: . a- " 6/ -j 12,11 <br />?tY Fax Number: <br />y ?fe <br />Contact Name: IM V? G Contact Title: <br />, <br />BillingAddress (If different from above address): Contact Name: <br />/- . D. 6 ? b g f! IV OR._r F} T.19 9 t <br />City: ? j E C TS County: 1?b R?f? G? State: D I`f Zlp?yya?i <br />'Telephone Number: 3 30_Fa7c Number: <br />b, ?-?so 33o-?a?_ Sv <br />e <br />SYate License Number: Issue Date: Expirarion Date: <br />s <br />Date of last survey: Medicare iNumber: Medicaid Number: <br />38'3 0 <br />? ? <br />Accreditino Agency: Expiration Date: <br />Type of Acereditation obtained: <br />77 <br />•'? ? •;! <br />Liability Carrier: Coverage Limits: <br />Poiicy Number: Expirarion Date: <br />If Self-insurerl, please supply doeumen#ation describixta yoar self-insurance program. <br />, . _ _. <br />. . . , . <br />Facility_Application -10/03; revised 12/05, 7/06, 9/06 Page 1 of 3