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Signature Date Please mail this completed Provider Application and all applicable attachments to Iowa Medicaid Enterprise Attn Provider Enrollment PO Box 36450 Des Moines Iowa 50315 Section B Organizational Data Master Provider Listing Use this list to identify your provider type code. Attach current certification document s as indicated on the list below Only the individuals or institutional categories listed by the business on this form are eligible for Medicaid reimbursement. Type Code Cate ...

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