Provider Contact Information

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1. Area of Interest
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*
2. Select a request
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3. First Name:
4. Last Name:
and / or
5. Medical Facility/Special Care Center Name:
6. Specialty/Function
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:
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*
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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