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If the applicant does not have a different D/B/A name this space should be left blank. If the applicant enters a D/B/A name it must match the information entered in section 2B of the Form CMS 855A if the doing business as block is checked* 3. Address The FQHC applicant must enter the same address as it entered in Section 4A of the Form CMS 855A as the practice location of the FQHC. The applicant must enter the street name and number the city/town state and zip code. If there is a suite number t ...

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