Provider Information


	Date Observed (Edit as needed)	*
	Provider Information:
	Legal Entity Name	*
	Legal Entity Phone Number (Format: 1234567890)
	Location Name	*
	Location Phone Number (Format: 1234567890)
	Address Line 1	*
	Address Line 2
	City	*
	State	*
	Zip Code (Format: 12345 or 12345-6789)	*
	County	*