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General Information
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Tax ID Number
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Practitioner's Name
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Practice Name
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Practice Address
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City, State, Zip
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Phone Number
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Fax Number
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Table description
Billing Information
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Billing Data
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Billing Company
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Billing Address
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City, State, Zip
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Phone Number
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Fax Number
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Remit Information
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Remit To Name
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Remit Address
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City, State, Zip
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