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Each party warrants that it has full power and authority to enter into this Agreement and the person signing this <br />Agreement on behalf of either party warrants that he/she has been duly authorized and empowered to enter into this <br />Agreement. <br />Provider shall be designated as a Participating Provider in the Networks set forth on the Provider Network <br />Attachment on the later of: (1) the Effective Date of this Agreement or; (2) as determined by Plan in its sole <br />discretion, the date Provider has met applicable credentialing requirements, standards of participation and <br />accreditation requirements. <br />PROVIDER LEGAL NAME ACCORDING TO W-9 FORM WITH DIBIA: County of Kittitas dba Kittitas County <br />Signatu-r'e, AuthorizedrRepresentative of Provider(s) <br />Date <br />G - 3-;-y <br />Printed: 0,44 y 'MAY012 5 SHJ�- 2 I F� <br />Name Title <br />Address: 205 W 5th Ave. Suite 1 <br />Street <br />Tax Identification Number (TIN): 916001349 <br />(Note: if any of the following is not applicable, please leave blank) <br />Phone Number: Sol -q aC2 — 7rj'Z 7 <br />Wellpoint Washington, Inc. <br />Ellensburg WA 98926 <br />City State Zip <br />WELLPOINT INTERNAL USE ONLY <br />THE EFFECTIVE DATE OF THIS AGREEMENT IS: <br />By: <br />Signature, Authorized Representative of Wellpoint <br />Printed: Preston W. <br />Name <br />Date <br />Director Provider Solutions, Wellpoint <br />Title <br />Washington Enterprise Provider Agreement PCS 15 1183932156 <br />© 2024 July — Wellpoint Washington_ Inc. <br />0510512425 <br />