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Appendix 4 <br />Your Practice Locations <br />Medical Group attests that this Appendix identifies all services and locations covered under this <br />Agreement. <br />�" ''f ad L n {,6 ^' s^ 4 1f `' `�.:o''@ xSy <br />m�LJ.V��siS©�+A�L]�ia°e���4i?iz?s`'�,....a` .@ ilk z`e ''�1 Y a ;. �xr��4 <br />4. Ls,. L�m..iC �V w.dS. 4^, <br />Practice Name Kittitas County <br />Street Address 307 W UMPTANUM RD <br />City ELLENSBU State WA Zi 98926 <br />RG p <br />Tax ID Number (TIN) 916001349 <br />National Provider ID (NPI) 1063226272 <br />PRACTICE LOCATIONS (complete one for each service location) <br />Primary Practice <br />Location Address: <br />Address: 205 W 5TH AVE STE 1 <br />City: ELLENSBURG <br />State: WA <br />Zip: 98926 <br />Tel #: (506) 962-7527 <br />Fax #: <br />Billing Address: <br />Address: 307 W UMPTANUM RD <br />City: ELLENSBURG <br />State: WA <br />Zip: 98926 <br />Tel #: (506) 962-7527 <br />Fax #: <br />Additional Service <br />Location Address: <br />Address: 205 W 5TH AVE STE 1 <br />City: ELLENSBURG <br />State: WA <br />Zip: 98926 <br />Tel 4: (506) 962-7527 <br />Fax #: <br />Billing Address: <br />Address: 307 W UMPTANUM RD <br />City: ELLENSBURG <br />State: WA <br />Zip: 98926 <br />Tel #: (506) 962-7527 <br />Fax #: <br />Mailing Address: <br />Address: 205 W 5TH AVE STE 1 <br />City: ELLENSBURG <br />State: WA <br />Zip: 98926 <br />Tel #:(506) 962-7527 <br />Fax #: <br />UIICISMGA.03.12,WA Parties bound to confidentiality under Section'About data and confidentiality' <br />-16- <br />