| Name | Description | Type | Additional information |
|---|---|---|---|
| Provider_ID | string |
Required |
|
| Type_of_Care | string |
Required |
|
| Provider_First_Name | string |
None. |
|
| Provider_Middle_Name | string |
None. |
|
| Provider_Last_Name | string |
None. |
|
| PrimaryContact_FirstName | string |
None. |
|
| PrimaryContact_LastName | string |
None. |
|
| PrimaryContact_Title | string |
None. |
|
| PrimaryContact_Phone | string |
None. |
|
| PrimaryContact_Extension | string |
None. |
|
| PrimaryContact_Email | string |
None. |
|
| Business_Facility_Name | string |
None. |
|
| Business_Survey_Phone | string |
None. |
|
| Business_Survey_Extension | string |
None. |
|
| Referral_Facility_Phone | string |
None. |
|
| Referral_Facility_Extension | string |
None. |
|
| Public_Email | string |
None. |
|
| RNR_Communications_Email | string |
None. |
|
| Website | string |
None. |
|
| Street_Address_1 | string |
Required |
|
| City | string |
Required |
|
| ZIP_Code | string |
Required |
|
| Cross_Streets | string |
None. |
|
| Cell_Phone | string |
None. |