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Date location will be closed/terminated:*
   
Name of the terminating location: *
 
Physical Address of Terming Location: *
 
City: *
 
State: *
 
Zip: *
 
Phone:  
 
Reason for termination: *
 
Where are practitioners who are working at this site going? - i.e., list site in Wisconsin, or list state if relocating (required by Wisconsin law).
At least one is required. :
Practitioner NameNew SiteTax ID# 
Add
* Indicates a required field.