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Practice Information
Business name as advertised
*
Legal business name
*
Founding year
Number of Employees
*
Toll-free phone number
Primary office email
Full business address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone number
Fax number
Full Business Address - Office Location 2 (if applicable)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone number - Location 2
Fax number - Location 2
Full Business Address - Office Location 3 (if applicable)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone number - Location 3
Fax number - Location 3
Full Business Address - Office Location 4 (if applicable)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone number - Location 4
Fax number - Location 4
Website
Team Information
Number of Doctors in Practice
*
1
2
3
4
5
6
Doctor 1 First Name
Doctor 1 Middle Name
Doctor 1 Last Name
Doctor 1 Credentials
Doctor 1 Birthdate
Doctor 1 NPI
Doctor 1 State License No.
Doctor 1 DEA No.
Have you earned a board certification?
No
Yes
If yes, please list all certifying boards
Doctor 1 contact phone
Doctor 1 primary email
Member of the following organizations (professional organizations, Chamber, BBB, etc.)
Doctor 2 First Name
Doctor 2 Middle Name
Doctor 2 Last Name
Doctor 2 Credentials
Doctor 2 Birthdate
Doctor 2 NPI
Doctor 2 State License No.
Doctor 2 DEA No.
Have you earned a board certification?
No
Yes
If yes, please list all certifying boards
Doctor 2 contact phone
Doctor 2 primary email
Member of the following organizations (professional organizations, Chamber, BBB, etc.)
Doctor 3 First Name
Doctor 3 Middle Name
Doctor 3 Last Name
Doctor 3 Credentials
Doctor 3 Birthdate
Doctor 3 NPI
Doctor 3 State License No.
Doctor 3 DEA No.
Have you earned a board certification?
No
Yes
If yes, please list all certifying boards
Doctor 3 contact phone
Doctor 3 primary email
Member of the following organizations (professional organizations, Chamber, BBB, etc.)
Doctor 4 First Name
Doctor 4 Middle Name
Doctor 4 Last Name
Doctor 4 Credentials
Doctor 4 Birthdate
Doctor 4 NPI
Doctor 4 State License No.
Doctor 4 DEA No.
Have you earned a board certification?
No
Yes
If yes, please list all certifying boards
Doctor 4 contact phone
Doctor 4 primary email
Member of the following organizations (professional organizations, Chamber, BBB, etc.)
Doctor 5 First Name
Doctor 5 Middle Name
Doctor 5 Last Name
Doctor 5 Credentials
Doctor 5 Birthdate
Doctor 5 NPI
Doctor 5 State License No.
Doctor 5 DEA No.
Have you earned a board certification?
No
Yes
If yes, please list all certifying boards
Doctor 5 contact phone
Doctor 5 primary email
Member of the following organizations (professional organizations, Chamber, BBB, etc.)
Doctor 6 First Name
Doctor 6 Middle Name
Doctor 6 Last Name
Doctor 6 Credentials
Doctor 6 Birthdate
Doctor 6 NPI
Doctor 6 State License No.
Doctor 6 DEA No.
Have you earned a board certification?
No
Yes
If yes, please list all certifying boards
Doctor 6 contact phone
Doctor 6 primary email
Member of the following organizations (professional organizations, Chamber, BBB, etc.)
Office Manager
*
Office Manager contact phone
*
Office Manager primary email
*
Who will be your main contact for billing?
*
Please list all contact information if not listed above.
Local Search
Hours of operation
*
Types of payment accepted
*
Cash
Personal Check
Debit Card
Insurance
Visa
Mastercard
Discover
Financing (Care Credit ect.)
American Express
Primary services (and products) offered
*
Brand name of services/products offered
Insurances accepted
*
Cities Serviced (in the order of importance)
*
Old Business Name, Addresses or Associates
Business tag line
Social Media
If Google verified, login email
If Google verified, login password
Facebook login email
Facebook login password
Instagram login email
Instagram login password
Yelp login email
Yelp login password
YouTube login email
YouTube login password
Other login email
Other login password
Website
Who is your website address registered through?
Login username
Login password
Who hosts your current website?
Backend login username
Backend login password
Practice Management System Used
Forms & Policies
Please attach any relevant forms, policies, care instruction sheets, and handouts.
File
Drop files here or
Other
Other information important for us to know
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Name
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