| Name | Value |
|---|---|
| NAME | STATE LICENSE |
| SOURCE LEVEL MINIMUM | LICENSING/GOVT AGENCY - EACH PROV |
| X12 CODE | 0B |
| VALID FOR PERFORMING PROVIDER | YES |
| ALLOWABLE FORM TYPE | BOTH INSTITUTIONAL AND PROFESSIONAL |
| ACTIVE | YES |
| STATE LICENSE # | YES |
| PROVIDER'S OWN ID | YES |
| STORED OUTSIDE OF BILLING | YES |