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BILLING ADDRESS FOR MWSUD SERVICES ONLY <br />Identify only if a common name and address appears on all Medical Group service location bills <br />Identification Num under thethat utilize the Medical ts <br />S <br />Practice Name: Kittitas County <br />Street Address: 307 W UMPTANUM RD <br />City: ELLENSBURG State:WA Zip: 98926 <br />Taxpayer ldentification Number(s) (TIN) 9 16001349 <br />National Provider 226272 <br />MADICAL GROI.'P LOCATION FOR MIUSUD SXRVICSS ONLY. List BOTH thc SETViCC <br />Location and the Billine Address for the Service Location <br />Billing Address for the Service Location (if <br />different from above) <br />Service Location <br />Medical Group NameMedical Group Name <br />Kittitas CountyKittitas County <br />Street AddressStreet Address <br />307 W UMPTANUM RD307 W UMPTANUM RD <br />ciwCitv <br />ELLENSBURGELLENSBURG <br />State and Zip CodeState and Zip Code <br />wA 98926w1^98926 <br />Phone NumberPhone Number <br />(s06)' 962-7s27(50o 962-7s27 <br />TIN Uf different from above) <br />National Provider ID (NPI) <br />ADDITIONAL MEDICAL GROUP LOCATIONS FOR MH/SUD SERVICES ONLY - LiSt BOTH <br />the Service Location and the Billing Address for the Service Location <br />Billing Address for the Service Location (if <br />different from above) <br />Service Location <br />Medical Group NameMedical Group Name <br />Street AddressStreet Address <br />CitvCity <br />State and Zip CodeState and Zip Code <br />Phone NumberPhone Number <br />TIN (Ifdifferent from above\ <br />National Provider ID (NPI) <br />Medical Group NameMedical Groun Name <br />Street AddressStreet Address <br />5 UnitedHealthcare <br />Confide ntial and Proprietary <br />Ge n, Amd. S MGA. B H. WA. 0 6. 2 5