1. Site NPI Number - Required (If no NPI #, Please email CHDPNews@ph.lacounty.gov)

2. Site Name - Required

3. Site Address - Required

4. City - Required

5. Zip Code - Required

6. Site Owner/Medical Director's Name

7. Site Email Address - Required

8. Re-Type Site Email Address - Required

9. Site Phone Number - Required

10. Alternative Phone Number - Optional

11. Site Fax Number

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