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General Details:

Health care Unit Name:          Type:
Specialization: Level of Care:
Plot Size(sq.m): No of Beds:
Registered: Yes        No
Owner/Chief/Doctor: Certification
(ISO,NABL,JCI):
          
Address:
Country: State:
District: City:
Pincode: STD Code:
Phone No: Other Phone No:
Mobile No : FAX :
Email: Website:
Landmark:
Contact Person for TPA: Mobile No:
Email:
Contact Person for Billing: Mobile No:
Email:

Google Map:

Longitude:                     Latitude:            
GooglePath:

Staff Details:

No of Resident Medical Officer:                                  No of Full Time
Consultant:
No of Nursing Staff: No of Technician         
Staff:
Do you practise
multiple tariff:
Yes        No Reason:

Bank Details:

Bank Name:         Accout No:
Branch Name:                                 PAN No:
MICR No: IFS Code:
Cheque in favour
of:
Service TAX No:        
Remarks: Ref:
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