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Get Form 1051

ATOR OF THE AGENCY/FACILITY (OR DESIGNEE). 1. a. Name of agency/facility Medi-Cal provider number Address (number, street) County ZIP code Number of patients Administrator Telephone number Name of agency/facility staff providing information Telephone number ( b. ( Title Email Address ) ) ) Name of licensee/parent corporation (if applicable) License number Telephone number Address (number, street) City State ( 2. Number of employees Telephone number ( c. Date ) ZIP code.

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