First Name

Last Name

Job Title

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Company

Facility Type Skilled Nursing Facility Assisted Living Facility Intellectual/Developmental Disability Care Center Continuing Care Retirement Center Transitional Care Center

Number of Patients Less than 25 25 - 50 50 - 100 >100

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

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