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BILLpVG AI)I)RESS FOR MHISUD S�RVIGES ONLY <br />Identify only if a common name and address appears on all Medical Group service location bills LL <br />that utilize the Medical Group's Taxpayer Identification Numbers) under the Agreement. <br />Practice Name: Kittitas County <br />Street Address: 307 W UMPTANUM RD <br />City: ELLENSBURG State: WA Zip: 98926 <br />Taxpayer Identification Number(s) (TIN) 916001349 <br />National Provider ID (NPI): 1063226272 <br />MEDICAL GROUP LOCATION FOR MWSUD SERVICES ONLY -"List BOTH ithe ,Service <br />Location an`d the Bill in Address far"thc'Service Location <br />Service Location <br />Billing Address for the Service Location (if <br />different from above) <br />Medical Group Name <br />Medical Group Name <br />Kittitas County <br />Kittitas County <br />Street Address <br />Street Address <br />307 W UMPTANUM RD <br />307 W UMPTANUM RD <br />city <br />City <br />ELLENSBURG <br />ELLENSBURG <br />State and Zip Code <br />State and Zip Code <br />WA 98926 <br />WA 98926 <br />Phone Number <br />Phone Number <br />506)962-7527 <br />506 962-7527 <br />TIN (If differentfirom above <br />National Provider ID(NM <br />ADDITIONAL MEDICAL GROUP LOCATIONS FOR MII/SUD SERVICES ONLY - List BOTH <br />the Service Location and the Billing Address for the Service Location <br />Service Location <br />Billing Address for the Service Location (if <br />different from above) <br />Medical Group Name <br />Medical Group Name <br />Street Address <br />Street Address <br />city <br />city <br />State and Zip Code <br />State and Zip Code <br />Phone Number <br />Phone Number <br />TIN Qf di erent ram above <br />National Provider ID NP <br />Medical Group Name <br />Medical Group Name <br />Street Address <br />Street Address <br />Gen.Amd.SNLGA BIL WA.06.25 - 5 - Unitedtlealthcare <br />Confidential and Proprietary <br />