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<br /> III <br /> TEXAS NHIC'S RECEIPT OF <br /> APPUCAllON <br /> MEDICAID <br /> WIC IMMUNIZATION APPLICATION <br /> -. <br /> PROVIDER OF SERVICE INFORMA T!ON <br /> þ.PPt!CANT NAt.E (INOIV.. GROUP, INC., DBA) TELEPHONE NUMBéR <br /> CITY OF SAN MARCOS WIC PROGRAM Alva Code (c; 1? )~c:;")_r::")f"'I") <br /> tk .",., Fat ~ rt - <br /> Auut"!ESS Of PHYSICAL LOCATION (NOT P.O. BOX) <br /> 630 E. HOPKINS <br /> Nurrber Street ¡:¡,...".,,¡.c:..... <br /> SAN ~1ARCOS TEXAS 78666 <br /> CiTV' <br /> ACCOUNTING ADDRESS I MAIL CHECK TO: <br /> Texas Department of Health Fiscal Division 1100 W. 49th St. <br /> I'fUrTO<lr tree! .. .. <br /> Austin Texas 78756 <br /> "';;V ::;- Lx> (.;cde <br /> IRS EMPLOYER"S TAX. 10 # (for yearly tax reponing) <br /> 74-6000182 ~ <br /> To the best of my knowledge, the information supplied on this 00 oo(Q)iF ~ 000 ~ ~~~ <br /> document is accurate and complete and is hereby released to <br /> National Heritage Insurance Company and Texas Department of # <br /> Human Services for ths purpose of issuing a Medicaid provider <br /> number. <br /> ¡ature of Authorized Representative I <br /> cY / ¿! ~~ County Spec. Type LocaJity Effeexive Dale <br /> 0 ¡gn <br /> City Manager 12/14/93 UlJ W W Ll.lJ "'"" <br /> <br /> - Title Dare <br /> Enrollment Date: Initials: <br /> ALL INFORMATION MUST BE COMPLETED OR MARKED '"N/A'" AND COHTAJN A VAUD SIGNATURE TO BE PROCESSED. <br /> RETURN COMPlETED FORM TO: <br /> Bureau of WIC Nutrition <br /> N Texas Dept. of Health y <br /> 1100 W. 49th street <br /> Austin, Texas 78756 .. <br />