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Docusign Envelope lD: CEBC6B3C-DFA1-4BOC-AFE8-6A4A63440086 <br />ExrnerrE <br />CoNTnacT REPRESENTATIvES ANI} CoNTAcT INF.oRMATIoN <br />Email <br />Phone <br />City <br />llflailing Address 2 <br />Mailing Address 1 <br />Contact Title <br />Contact Name <br />Kittitas County Sheriffls Office Jail <br />Edward. Buntin@co.kittitas.wa.us <br />509-962-7527 <br />Ellensburg <br />205 W 5th Ave. Stel <br />Lieutenant <br />Edward Btmtin <br />State <br />Fax <br />WA zip 98926 <br />Email <br />City <br />Mailing Address <br />ATTN: Provider Contracting Department <br />COMMUNITY HEALTH PLAI\ of WASHINGTON (CIIPW) <br />Provider. Contractine@CHPW.ore <br />Seattle <br />111 1 Third Avenue, Suite 400 <br />State WA zip 98t01-3292 <br />Email <br />Phone <br />City <br />Mailing Address <br />ATTN: Provider Relations Department <br />Provider.Relations@CHP W.org <br />(206) s21-8833 <br />Seattle <br />I I l1 Third Avenue, Suite 400 <br />State <br />Fax <br />WA <br />(206) 613 - s018 <br />zip 9810r-3292 <br />Email <br />City <br />l![siling Address <br />ATTN: Credentialing Department <br />provider. Credenti al ine(Achpw. or g <br />Seattle <br />1111 Third Avenue, Suite 400 <br />State WA zip 98101-3292 <br />2020 Facility Agmt - Template Page 51 of5l Contract #{Contract #}-{PRC Agreement ID}