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Get Merc Training Site Application - Minnesota Department Of Health - Health State Mn

Ent in the Minnesota Health Care Program on record with the Minnesota Department of Human Services. Facility Name Address City State Zip MN - CEO/CFO or Authorized Representative Title Email Address Phone Fax Medicaid Provider Type Facility Hospital Physician Clinic (not provider-based) Pharmacy (non-hospital) Dental Clinic Chiropractic Clinic Other (please specify) Federal Tax ID (FEIN) 9 digits National Provider ID (NPI) 10 digits If the facility s NPI.

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