*SSA State/County Code *Specialty Code *National Provider Identifier (NPI) Number Facility Name *Street Address *City *State *ZIP Code *# of Staffed, Medicare-Certified Beds RPPO-Specific Letter of Intent? Exception to Written (Y/N) Only applicable Agreements? (Y/N) for MA Applicants
| File Type | application/pdf |
| File Title | HSD Table Templates |
| Author | CGI Federal |
| File Modified | 2024-03-04 |
| File Created | 2024-03-04 |