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Provider Demographic Information - CLW UAT TEST ONE

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PROVIDER DEMOGRAPHIC INFORMATION Supporting line for group header


Name:	CLW UAT TEST ONE
Address:	3824 HIDDEN SPRINGS DR HARRISBURG, PA 17110-9515
Phone:	(717) 555-5555
Web Site:	N/A

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PROVIDER CERTIFICATION INFORMATION Supporting line for group header

Click here to view Provider Certification Information

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PROVIDER'S PARENT/ REGIONAL OFFICE Supporting line for group header


Type:	Corporate Office
Name:	CLW UAT TEST ONE
Address:	ALLENJWALBERT HARRISBURG, PA 17110-9438
Phone:	(717) 555-5555

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PROVIDER SERVICES AND RATES Supporting line for group header


County : Dauphin
\|Service Name / Level	\|Rate

CLW Test Service 1 - mapped	Not Set
CLW Test Service 2 - mapped	Not Set
CLW Test Service 3 EDIT AGAIN	Not Set
In-Home & Commnty Supprts (Lvl 1, 1:3)	Not Set

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