NATIONAL PROVIDER IDENTIFIER (NPI) APPLICATION/UPDATE FORM ‘Hens FT or WE al ifonnatin so apie Ue ny Hae or bv ik o nt ue pon Falare to provide page 23cm Suh complete anf scarateinfxmaton my cee yout apleton tobe retured and Jy posing. naan, {ona eputance pabae being receive by owarr i he resorts do ot moh the fematon yo osrRnbed a sem tration samt on hs ppaton cept fr Socal Secorty Numb Saad “aepye ene urbe se ate of Bt) ay be sede sane on he mera SECTION 7 BASIC INFORMATION. ', Reason for Submit of tls Form (aqied (Ou) proie ane Reason (or Submit andor MH pes. actions forme eee 1h itis Apptaton 2. © Deacthation oe nstrton) Penatr requ fl or nit ppiation oly) Ie ie — 2. 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CUE Ga | COUR aT Wek OF tran USD] Gane 08/19/1980 Georgia Ole Genele cal Seca ir CH en SRA Tapper Waniean Wor OTA es 3003 ‘deg nas is Carn nd ami i a apo an Ta Be) “. Wome™ (Legal tusiness Name) 2. Employer Mentification Wurmber® (iN Ta a ETA ripe kare ———— [ret uaneisName CONIA Home Tother Fem amie 7{JECTION 3: BUSINESS ADDRESSES AND OTHER INFORMATION “a. Business Malling Address Information D ot repor your eset es wis ah you us aig Ades) gs lng Aes 1 (Set Haba and ae or FO Band AW N Minin Bases sai gan Raa Code™ oe ‘Valdosta Gs ee 5 sn oa ae oe "Bar TGS MEAT NOIR A CTSNET le As Cae) 229-234-5556 229-234-5887 1B. 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DTT Tbe aan EGON CONTACT EREOH ‘A Contet Person's information A. ntect Peron rac nuber fan indi we can be reached oan ucts regarding the information Sete ths apa. the contact penn cone th heath ae prove, re nro) 7. fea Me i) a 5 a ase Me. |cralg r Bishop So. acre, MBL BOTT RT DO. Tena 5 Fens Roba Ore es Coa Tae lgbishope@gmaiLcom 229-518-2225 Forth wos oor sd font cit of yeu las ie he webbed HF pos at th olloing aess MeL Fon geil bs eck sey uy for you to gt Your NL, Or Snd he completed aged pletion to: ‘ol eemerto, RO, box 65, Fogo, ND S089 ie at eta carton efanutn eas omni ce eee ec sonoe Spero naw peo oa ong fe cng nana ae ee itera, rea ei aa pte teen alin yu et cay os nt ings resin i am ae wl 8, A Raper Saray rt a x bsint nd Mo 150 Dot od igh oth a eee ee eee eee Fomor 3