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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 Participatlng Provider ln 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 Provlder has met appllcable credentialing requirements, standards of participation and <br />accreditati on requ i rements. <br />PROVIDER LEGAL NAME ACCORDING TO W-g FORM WITH D/B/A: County of Kittitas dba Klttitas County <br />By e^(@ tulq 6' 3'* <br />Signatu6, Rutnorfieo'RepresentatMe oiProvide(s) <br />Printed: CLeV MUER J <br />Date <br />stfrRtFr <br />Name <br />Address: 205 WSth Ave, Suite 1 <br />Street <br />Tax ldentification Number (TlN)916001349 <br />(Note: if any of the following is not applicable, please leave blank) <br />phone Number, 5ol -962 -75?.7 <br />Wellpoint Washington, lnc. <br />Title <br />Ellensburg WA 98926 <br />City State Zip <br />06t2412025 <br />Date <br />Director Provider Solutions, Wellpoint <br />THE <br />By: <br />Signature, <br />Printed; Preston W. Cody <br />WELLPOINT INTERNAL USE ONLY <br />0710112025 <br />REEMENT IS: <br />of Wellpoint <br />Name <br />Weshington Enterprise Providor Agr€€ment PCS <br />@20?4 July - Vvellpoint Washington, lnc. <br />Title <br />'t1839321s615 <br />05/05/2025