DBA Name definition

DBA Name. Enter the DBA name if applicable. • Street Address: Enter the account holder’s street address. • Enter the account holder’s city, state, and zip code. • Account Holder Tax Identification Number: Enter the tax identification number as reported to the IRS. If the business is a group, organization or corporation, provide the Federal employer identification number (EIN). If enrolling as an individual provide your Social Security Number.
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Examples of DBA Name in a sentence

  • See Instructions on Page 3 New Enrollment Change Enrollment Cancel Enrollment Document Included: Voided Check Bank Letter Account Holder Legal Name: DBA Name if different from above: Legal Address: number, street, and apt.

  • Last Name First Name M.I. Jr., Sr., as applicable Gender (M/F) Birth Date (mm/dd/yy) Professional Degree Social Security Number (Billing Purposes Yes No) Clinical Name or D.B.A. Name Tax I.D. Number (Billing Purposes Yes No) NP, CRN FA or PA Supervising/Authorizing Physician: Last Name, First Name, Prof.

  • Change in Company DBA Name, Address, Telephone or Fax Number Contact Customer Services.

  • DBA Name: ................................................................................................................................................

  • Louisiana Medicaid MCO Number (7 digits) Submitter Number (7 digits) (leave blank if applying for new number) DBA Name of MCO: Billing Agent/ Submitter Name / Name of Business that will be submitting encounters (business name or third party ▇▇▇▇▇▇’▇ name): Contact Name: Contact Phone Number: The Medicaid File can only hold a maximum of three Submitter numbers per Medicaid MCO Number at any one time.

  • NOT VALID WITHOUT SIGNED EXHIBIT B PPO‌ or ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇.▇▇▇ for complete Payment Schedule Last Name First Name M.I. ▇▇., ▇▇., as applicable Gender (M/F) Birth Date (mm/dd/yy) Professional Degree Social Security Number (Billing Purposes Yes No) Clinical Name or D.B.A. Name Tax I.D. Number (Billing Purposes Yes No) NP, CRN FA or PA Supervising/Authorizing Physician: Last Name, First Name, Prof.

  • Provider Name Provider Name Text ABC Co. DBA Name “Doing-business-as” name Text Superfone, Inc.

  • Seller and Dealer desire to amend the Agreement to reflect a change in DBA Name.

  • NOT VALID WITHOUT SIGNED EXHIBIT B PPO‌‌ or ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇.▇▇▇ for complete Payment Schedule Last Name First Name M.I. ▇▇., ▇▇., as applicable Gender (M/F) Birth Date (mm/dd/yy) Professional Degree Social Security Number (Billing Purposes Yes No) Clinical Name or D.B.A. Name Tax I.D. Number (Billing Purposes Yes No) NP, CRN FA or PA Supervising/Authorizing Physician: Last Name, First Name, Prof.

  • Artist First and Last Name plus DBA Name Address: EmailPhone: Customer First and Last Name:Address: Email: Phone: Total Price (Amount): Deposit Required upfront (Amount): Remainder Due at completion (Amount):Payment(s) will be processed through an invoice sent via (Insert artist or Business name} online store, PayPal, CashApp or Venmo.