Provider Enrollment - Valencia - PRIA Enrollment

eCoin Patient Access Program

Program Registration Form

Provider Enrollment - Valencia

Practice Name *

Practice Phone Number *

Practice Fax Number *

Practice Address *

Practice Address

Practice Address

Practice Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Practice Tax ID *

Practice NPI *

Admin Contact Name (First and Last) *

Admin Contact Email *

Admin Contact Phone *

Valencia Sales Representative Name *

Physician Name (1) *

Physician NPI (1) *

Physician Tax ID (1) *

Physician PTAN (1)

Physician Name (2)

Physician NPI (2)

Physician Tax ID (2)

Physician PTAN (2)

Additional Location (1)

Additional Location Address (1)

Additional Location Address (1)

Additional Location Address (1)

Additional Location Address (1)

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Phone (1)

Tax ID (1)

NPI (1)

Facility Name *

Facility Address *

Facility Address

Facility Address

Facility Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Facility Phone *

Facility Tax ID *

Facility NPI *

Facility Name (2)

Facility Address (2)

Facility Address (2)

Facility Address (2)

Facility Address (2)

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Country

Country

Facility Phone (2)

Facility Tax ID (2)

Facility NPI (2)

Date: Onboarding Call Availability (Option 1)

Time (EST)

Date: Onboarding Call Availability (Option 2)

Time (EST)