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

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2. Site Name - Required

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3. Site Address - Required

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4. City - Required

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5. Zip Code - Required

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6. Site Owner/Medical Director's Name

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7. Site Email Address - Required

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8. Re-Type Site Email Address - Required

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9. Site Phone Number - Required

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10. Alternative Phone Number - Optional

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11. Site Fax Number

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