PRACTICE LOCATION ADD
* PLEASE FILL OUT FOR EACH INDIVIDUAL PRACTICE LOCATION
County
Practice Name
*
Practice Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code + 4
Office Hours
*
Is Primary Practice?
*
Yes
No
Federal Tax ID
*
Practice NPI
*
Practice Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Fax Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Email
*
example@example.com
Does your group provide services in any other language other than English?
*
Yes
No
Are you accepting new patients?
*
Yes
No
Is this Practice Location ADA compliant?
*
Yes
No
Are you Accredited?
*
Yes
No
Patient Age Range
*
i.e 0-99
Practice Effective Date
*
-
Month
-
Day
Year
After Hours Service
*
Please Select
Voicemail
Answering Service
N/A
Office Manager Name
*
First Name
Last Name
Office Manager Email
example@example.com
Submit
Should be Empty: