| *SSA State/County Code | Facility or Service Type | *Specialty Code | *National Provider Identifier (NPI) Number | *# of Staffed, Medicare-Certified Beds | Facility Name | *Street Address | *City | *State | *ZIP Code | Uses CMS MA Contract Amendment? (Y/N) | RPPO-Specific Exception to Written Agreements? (Y/N) |
| OMB Control Number: 0938-1346 (Expires: 12/31/202x) |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |