Provider Credentialing Change Form


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Title Provider Credentialing Change Form
Description

Providers use this form to notify L&I of a change of their business address, billing address and account termination. Also has info on how to notify L&I on a tax ID (EIN) number change, tax ID address change and/or name change.

Document number F245-365-000
How to get this document
Keywords address change, change address, change of address, Credentialing, provider, Tax ID number
Alt Language(s)
Valid dates 02/2014
Contact information Provider Feedback
Websites For Medical Providers

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