example - dme w900000 wcmed insurance 16 avengers …
Post on 20-Nov-2021
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W900000WCMed Insurance16 Avengers StreetWhite Plains, NY 10604
Coyote, Wiley E 07 06 1972
124 Roadrunner Avenue 1 Boulder Circle
Staten Island NY NY
10306 111 1111111
G9999999
Coyote^^^Wiley Y4 0000WC1700010000
WCMed Insurance
Signature on File
05 14 19 4310B 4567890
Foghorn, Rooster MD 1111111119
0M25511
01 08 20 01 08 20 12 E2631 NU A 252 10 7 8822222229
261211111 36111-52222 252 102222222
OrthoDME Supplies OrthoDME Supplies2 Acme Street, Suite A 2 Acme Street, Suite A
Robert Fastus New York, NY 10022 New York, NY 1002201/10/2020 8822222229 8822222229
222
987-65-4321
ACME ZipRunners
Manhattan
10001 888 8888888
EXAMPLE - DME
REFX5016182-8^^^G2CIM^^^PWK09EAC00985621^^^NTEADD20200302
DK
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