State Form 44885 - Application For License To Operate A Hospital Page 2
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4E. Additional Services and/or Off-site Practice Locations Operated Under Hospital License:
If not applicable, leave blank. Do not list on-site skilled or distinct part units unless located off-site. (use additional sheet if necessary)
Provider Number if different
Type of Service
Name
Address
from Hospital
Blood Center
Hospice
Home Health
Other Off-Site Locations
List below:
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Parent category: Legal