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Attach additional sheets when necessary. Are you presently open No If yes when did you open / M If no when you anticipate opening D Y List the name of the owner s of the business and their social security number s and percentage of ownership* The names must match the names given on question 5 of the Disclosure of Ownership and Control Form* List any New York State NYS Medicaid Program provider numbers National Provider Identifiers NPI or professional licenses held by the owners. If a corporatio ...

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