Application to Operate a Hospital - ND Health & Human Services

Type of Application

Type of Application


Initial Application	Ownership Change Application

Facility Information

Facility Information

Please provide the facility information below.


Official Name of Hospital	Doing Business as Name
Total Bed Capacity #:	NPI Number

Address/Phone Information

Address/Phone Information

Physical Address

Physical Address


Street Address		County
City	State	ZIP Code

Mailing Address

Mailing Address


Address
City	State	ZIP Code


Business Telephone Number	Fax Number
E-Mail Contact Name	E-Mail Address

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