Service Location Address
Complete the fields on this page and select the Save and Continue button to continue with this application
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* Indicates a required field.
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Practitioner Information
Service Location Physical Address
This address must be a physical address where a practitioner maintains an office, holds office hours/sets appointments and renders services. A post office box is not a valid Service Location Physical Address.
Verify your selection of the service location physical address state prior to saving this page. Once this information is saved, it cannot be changed. If this information is incorrect, you will need to begin a brand new application.
After this information is saved, you will have the option to enter different address information for Mail-To, Pay-To, and Home Office Addresses.