Application - Facility-Agency - 20180430 2026

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  1. Click ‘Get Form’ to open the Application - Facility-Agency - 20180430 in our editor.
  2. Begin by entering the complete name of your facility or agency in the designated field.
  3. Select the appropriate action request by checking the relevant box for Initial Enrollment, Revalidation, or Reactivation.
  4. Input your National Provider Identifier (NPI) Number and taxonomy codes. If you have more than four taxonomies, attach an additional sheet.
  5. Fill in the requested effective date for your application and provide your provider type number along with its description.
  6. Complete all sections regarding contact information, business type, licenses, and any required documentation as specified in the checklist.
  7. Review all entries for accuracy before signing the application using our platform’s signature feature.

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