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1. Area of Interest

* 2. Select a request

3. First Name:

4. Last Name:

and / or

5. Medical Facility/Special Care Center Name:

7. Street Address:

8. City:

9. State:

10. Zip Code

* 11. Contact Person:

* 12. Contact Person's E-Mail Address:

* 13. Phone Number:

14. Alternative Phone Number:

15. Fax Number:

* 16. NPI Number (If no NPI#, please type 9999999)

17. Additional NPI Number #1

18. Additional NPI Number #2

* Required - Must answer question.
For technical assistance, our Help Desk can be reached

Monday through Friday - 8:00 a.m. to 5:00 p.m.

Phone: 626-569-6630
E-Mail: CMSNetSupport@ph.lacounty.gov

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