CHDP Provider Contact Information

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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