Covered Entity Details

DSH450237M CHRISTUS SANTA ROSA HEALTH SYSTEM (Terminated) - information as of 6/6/2025 12:41:19 PM

Main Details

Name

CHRISTUS SANTA ROSA HEALTH SYSTEM

Subdivision Name

CHRISTUS Santa Rosa Wound Care

Type

Disproportionate Share Hospital

Rural

340B ID

DSH450237M

Medicare Provider Number

450237

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

9/11/2012

Participating Start Date

10/1/2012

Participating Approval Date

9/19/2012

Last Recertification Date

8/31/2016

Termination Date
Termination Reason

1/1/2017
DSH percentage below statutory minimum

Contacts

Authorizing Official

The Children's Hospital of San Antonio
Linda Kirks, Regional VP/CFO
(210) 704-2624

Primary Contact

CHRISTUS Santa Rosa Health System
Dustyn Tysdal, REGIONAL DIRECTOR OF PHARMACY
(210) 704-0130

Addresses

Street Address

2833 Babcock Road, Suite 105
Tower 2
San Antonio, TX 78229

Billing Address

CHRISTUS Santa Rosa Health System
2827 Babcock Road
San Antonio, TX 78229

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
TX	0208449-01,0944860-01
		1194787218

Shipping Addresses

Shipping Address 1

CHRISTUS Santa Rosa Health System
2827 Babcock Road
San Antonio, TX 78229

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH450237AA	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Pedi OP Day Surgery	11212 State Highway 151	San Antonio	TX	Active
DSH450237AL	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - Emergency Room	600 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237AM	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - LDRP	600 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237AN	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - Cardiac Cath	600 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237AP	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - Day Surgery	600 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237AQ	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital New Braunfels - Hyper Oxyg Ther	600 North Union Avenue	New Braunfels	TX	Terminated
DSH450237AR	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital New Braunfels - Wound Care	600 North Union Avenue	New Braunfels	TX	Terminated
DSH450237AS	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - O/P Chemotherap	Medical Plaza Building, 598 North Union Avenue, 1st Floor	New Braunfels	TX	ToBeTerminated
DSH450237AT	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - Outpatient Radiology 1	600 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237AU	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	MC Wound Care Center Downtown	315 N. San Saba	San Antonio	TX	Terminated
DSH450237AV	Child	DSH	SANTA ROSA HEALTHCARE	Creekside Crossing ED	244 Creekside Crossing	New Braunfels	TX	ToBeTerminated
DSH450237AW	Child	DSH	SANTA ROSA HEALTHCARE	Alon Emergency Center	11503 Northwest Military Highway	San Antonio	TX	Active
DSH450237AX	Child	DSH	SANTA ROSA HEALTHCARE	Creekside Crossing OP Imaging - Radiology	244 Creekside Crossing	New Braunfels	TX	ToBeTerminated
DSH450237AZ	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA HOSPITAL-WESTOV / LDRP	11212 STATE HWY 151 BLDG 3	SAN ANTONIO	TX	Terminated
DSH450237BA	Child	DSH	SANTA ROSA HEALTHCARE	Med Surg Observation Beds / Med Surg D	600 N UNION AVE	NEW BRAUNFELS	TX	ToBeTerminated
DSH450237BB	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA HOSPITAL Observation Beds / Intermd Cre-Gen	600 N UNION AVE	NEW BRAUNFELS	TX	Terminated
DSH450237BC	Child	DSH	SANTA ROSA HEALTHCARE	RAS Hematology - Laboratory	403 Treeline Park	San Antonio	TX	Active
DSH450237BD	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Spine Center	2833 BABCOCK RD	San Antonio	TX	Active
DSH450237BE	Child	DSH	SANTA ROSA HEALTHCARE	RAS Central Service - Supply	403 Treeline Park	San Antonio	TX	Active
DSH450237BF	Child	DSH	SANTA ROSA HEALTHCARE	RAS ENDOSCOPY - Endoscopy - Endoscopy	403 Treeline Park	San Antonio	TX	Terminated
DSH450237BG	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Cardiothoracic Center - New Braunfels	730 N HOUSTON AVE	New Braunfels	TX	ToBeTerminated
DSH450237BH	Child	DSH	SANTA ROSA HEALTHCARE	ECC OB ED Unit at Santa Rosa Hospital Westover Hills	11212 State Highway 151	SAN ANTONIO	TX	Active
DSH450237BJ	Child	DSH	SANTA ROSA HEALTHCARE	RAS EKG - Cardiology	403 Treeline Park	San Antonio	TX	Active
DSH450237BK	Child	DSH	SANTA ROSA HEALTHCARE	RAS LAB - GENERAL 1 - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237BL	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Hyper Oxygen Therapy	11212 State Highway 151	San Antonio	TX	Active
DSH450237BM	Child	DSH	SANTA ROSA HEALTHCARE	RAS SURGERY-GENERAL - Surgery	403 Treeline Park	San Antonio	TX	Active
DSH450237BN	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Surgical Solutions - Bariatrics	11212 STATE HIGHWAY 151, BLDG 2	San Antonio,	TX	Active
DSH450237BP	Child	DSH	SANTA ROSA HEALTHCARE	RAS MICROBIOLOGY - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237BQ	Child	DSH	SANTA ROSA HEALTHCARE	RAS Cat Scanner - Imaging - Cat Scanner	403 Treeline Park	San Antonio	TX	Active
DSH450237BR	Child	DSH	SANTA ROSA HEALTHCARE	RAS PHYS THERAPY - Physical Therapy	403 Treeline Park	San Antonio	TX	Active
DSH450237BS	Child	DSH	SANTA ROSA HEALTHCARE	RAS Anesthesiology - Anesthesiology	403 Treeline Park	San Antonio	TX	Active
DSH450237BT	Child	DSH	SANTA ROSA HEALTHCARE	RAS Blood Bank - Transfusion	403 Treeline Park	San Antonio	TX	Active
DSH450237BU	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services - MRI	Medical Plaza Building, 598 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237BV	Child	DSH	SANTA ROSA HEALTHCARE	RAS Chemistry - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237BW	Child	DSH	SANTA ROSA HEALTHCARE	RAS RESPIR THERAPY - Respiration Therapy	403 Treeline Park	San Antonio	TX	Active
DSH450237BX	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Day Surgery - Operating Room	11212 State Highway 151	San Antonio	TX	Active
DSH450237BY	Child	DSH	SANTA ROSA HEALTHCARE	RAS REFERENCE LAB 1 - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237BZ	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services - CT Scan	600 N. Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237CA	Child	DSH	SANTA ROSA HEALTHCARE	RAS ULTRASOUND - Imaging - Ultrasound	403 Treeline Park	San Antonio	TX	Active
DSH450237CB	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA HOSPITAL Outpatient Observation Beds / Intermd Cre-Gen - Adults & Pediatrics	600 N UNION AVE	NEW BRAUNFELS	TX	ToBeTerminated
DSH450237CC	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services - Laboratory	600 N. Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237CD	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Orthopedic & Sports Medicine Clinic	2833 BABCOCK ROAD	San Antonio	TX	Active
DSH450237CE	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA NEUROSURGICAL SPINE - MEDICAL CENTER - NEUROSURGICAL SPINE - NEUROSURGICAL SPINE	423 TREELINE PARK	San Antonio	TX	Terminated
DSH450237CF	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services - Radiology Diagnostic	Medical Plaza Building, 598 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237CG	Child	DSH	SANTA ROSA HEALTHCARE	RAS RECOVERY ROOM - Recovery	403 Treeline Park	San Antonio	TX	Active
DSH450237CH	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Neurosurgical Spine - Medical Center	2829 Babcock Rd	San Antonio	TX	Active
DSH450237CJ	Child	DSH	SANTA ROSA HEALTHCARE	RAS SEROLOGY - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237CK	Child	DSH	SANTA ROSA HEALTHCARE	RAS HIST-CYT-PATH - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237CL	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Orthopedic & Sports Medicine Clinic- WH	11212 STATE HIGHWAY 151	San Antonio	TX	Active
DSH450237CM	Child	DSH	SANTA ROSA HEALTHCARE	RAS URINANALYSIS - Lab Services	403 Treeline Park	San Antonio	TX	Active
DSH450237CN	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services - Radiology - Therapeutic	Medical Plaza Building, 598 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237CP	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Orthopedic and Sports Medicine	423 Treeline Park	San Antonio	TX	Active
DSH450237CQ	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Urology Clinic	2833 BABCOCK RD	SAN ANTONIO	TX	Active
DSH450237CR	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS SANTA ROSA HEART & VASCULA - Heart and Vascular Clinic	479 OXFORD DR	NEW BRAUNFELS	TX	ToBeTerminated
DSH450237CS	Child	DSH	SANTA ROSA HEALTHCARE	NEW BRAUNFELS - NEUROSURGICAL SPINE	11212 STATE HIGHWAY 151	SAN ANTONIO	TX	Active
DSH450237D	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital - New Braunfels - Imaging and Lab Services	Medical Plaza Building	New Braunfels	TX	Terminated
DSH450237E	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Imaging Center - Alamo Heights	423 Treeline Park	San Antonio	TX	Terminated
DSH450237F	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	Rehabilitation Services - Pulmonary Rehab	750 Landa Street	New Braunfels	TX	Terminated
DSH450237G	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	Rehabilitation Services - Cardiac Rehab	750 Landa Street	New Braunfels	TX	Terminated
DSH450237H	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	Rehabilitation Services - Physical Therapy	750 Landa Street	New Braunfels	TX	Terminated
DSH450237J	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	Rehabilitation Services - Speech Therapy	750 Landa Street	New Braunfels	TX	Terminated
DSH450237K	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	Rehabilitation Services - Occupational Therapy	750 Landa Street	New Braunfels	TX	Terminated
DSH450237L	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital New Braunfels - Wound Care	Medical Plaza Building, 598 North Union Avenue	New Braunfels	TX	Terminated
DSH450237M	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Wound Care	2833 Babcock Road, Suite 105	San Antonio	TX	Terminated
DSH450237N	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hyperbaric Center	2833 Babcock Road, Suite 105	San Antonio	TX	Active
DSH450237P	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital New Braunfels - Hyperbaric Center	Medical Plaza Building, 598 North Union Avenue	New Braunfels	TX	ToBeTerminated
DSH450237Q	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Health System Rehabilitation Center for Adults and Children	2701 Babcock Road	San Antonio	TX	Terminated
DSH450237T	Child	DSH	SANTA ROSA HEALTHCARE	Alamo Heights - Radiology - Diagnostic	403 Treeline Park	San Antonio	TX	Active
DSH450237U	Child	DSH	SANTA ROSA HEALTHCARE	Alamo Heights - Emergency Room	403 Treeline Park	San Antonio	TX	Active
DSH450237V	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Emergency Room	11212 State Highway 151	San Antonio	TX	Active
DSH450237W	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Endoscopy/G.I.	11212 State Highway 151	San Antonio	TX	Active
DSH450237X	Child	DSH	SANTA ROSA HEALTHCARE	CHRISTUS Santa Rosa Hospital Westover Hills - Cardiac Cath	11212 State Highway 151	San Antonio	TX	Active
DSH450237Y	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital Westover Hills - Day Surgery	11212 State Highway 151	San Antonio	TX	Terminated
DSH450237Z	Child	DSH	CHRISTUS SANTA ROSA HEALTH SYSTEM	CHRISTUS Santa Rosa Hospital Westover Hills - Med/Surg D	11212 State Highway 151	San Antonio	TX	Terminated

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Primary Contact	Update	Profile Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107040130	Tysdal, Dustyn REGIONAL DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107040130	6/11/2024 3:05 PM
Contacts	Primary Contact	Update	Profile Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107042935	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107040130	6/11/2024 3:04 PM
Contacts	Primary Contact	Update	Group Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS ST MICHAEL HEALTH SYTEM 9036142928	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Health System 2107042935	10/25/2021 11:27 AM
Contacts	Primary Contact	Update	Profile Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Hospital - New Braunfels 8306435377	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS ST MICHAEL HEALTH SYTEM 9036142928	2/20/2020 1:19 PM
Contacts	Primary Contact	Update	Hospital Type Change Request	Tysdal, Dustyn DIRECTOR OF PHARMACY 8306435377	Tysdal, Dustyn DIRECTOR OF PHARMACY CHRISTUS Santa Rosa Hospital - New Braunfels 8306435377	4/16/2018 9:23 AM
Contacts	Authorizing Official	Update		Kirks, Linda Regional VP/CFO 2107042624	Kirks, Linda Regional VP/CFO The Children's Hospital of San Antonio 2107042624	10/9/2017 3:50 PM
Contacts	Authorizing Official	Update		Marquart, Tricia Interim Regional Chief Financial Officer 2107048773	Kirks, Linda Regional VP/CFO 2107042624	7/25/2017 10:25 AM
Contacts	Signed By	Insert			Barnett, Shawn Regional Chief Financial Officer 2107042624	2/21/2017 1:32 PM
Addresses	Main Address	Insert			2833 Babcock Road, Suite 105 Tower 2 San Antonio, TX 78229	12/19/2016 8:17 AM
Contacts	Primary Contact	Update		Richerson, Mark A. Director of Pharmacy 2107042935	Tysdal, Dustyn DIRECTOR OF PHARMACY 8306435377	12/19/2016 8:17 AM
Dates	Last Date That 340B Drugs Purchased	Update			11/28/2016 12:00:00 AM	12/19/2016 8:17 AM
Details	State	Update		Active	Terminated	12/19/2016 8:17 AM
Terminations	Termination Date	Update			1/1/2017 12:00:00 AM	12/19/2016 8:17 AM
Terminations	Termination Effective Date	Update			11/30/2016 12:00:00 AM	12/19/2016 8:17 AM
Terminations	Termination Reason	Update			DSH percentage below statutory minimum	12/19/2016 8:17 AM
Details	Last Recertification Date	Update		8/25/2015 12:00:00 AM	8/31/2016 12:00:00 AM	8/31/2016 12:25 PM
Addresses	Billing Address	Update		CHRISTUS Santa Rosa Health System 333 North Santa Rosa Street San Antonio, TX 78207	CHRISTUS Santa Rosa Health System 2827 Babcock Road San Antonio, TX 78229	8/25/2015 10:16 AM
Addresses	Shipping Address	Update		CHRISTUS Santa Rosa Health System 333 North Santa Rosa Street San Antonio, TX 78207	CHRISTUS Santa Rosa Health System 2827 Babcock Road San Antonio, TX 78229	8/25/2015 10:16 AM
Details	Last Recertification Date	Update		8/26/2014 12:00:00 AM	8/25/2015 12:00:00 AM	8/25/2015 10:16 AM
Addresses	Billing Address	Insert			CHRISTUS Santa Rosa Health System 333 North Santa Rosa Street San Antonio, TX 78207	8/25/2015 10:16 AM
Addresses	Shipping Address	Insert			CHRISTUS Santa Rosa Health System 333 North Santa Rosa Street San Antonio, TX 78207	8/25/2015 10:16 AM
Contacts	Authorizing Official	Insert			Marquart, Tricia Interim Regional Chief Financial Officer 2107048773	11/14/2014 2:16 PM
Details	Last Recertification Date	Update		9/12/2013 12:00:00 AM	8/26/2014 12:00:00 AM	8/26/2014 8:47 PM
Details	Last Recertification Date	Update			9/12/2013 12:00:00 AM	9/12/2013 3:17 PM
Contacts	Primary Contact	Insert			Richerson, Mark A. Director of Pharmacy 2107042935	8/12/2013 6:45 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/12/2013 6:44 AM
Medicaid Billing	Medicaid: Number	Insert			0208449-01	8/12/2013 6:44 AM
Medicaid Billing	Medicaid: State	Insert			TX	8/12/2013 6:44 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/12/2013 6:44 AM
Medicaid Billing	Medicaid: Number	Insert			0944860-01	8/12/2013 6:44 AM
Medicaid Billing	Medicaid: State	Insert			TX	8/12/2013 6:44 AM
Medicaid Billing	NPI: Number	Insert			1194787218	8/12/2013 6:44 AM
Details	340B ID	Update		IS-JH-DSH450237M	DSH450237M	9/19/2012 4:45 PM
Dates	Participating Approval Date	Update			9/19/2012 12:00:00 AM	9/19/2012 4:45 PM
Details	State	Update		Pending	Active	9/19/2012 4:45 PM
Dates	Start Date	Update			10/1/2012 12:00:00 AM	9/19/2012 4:45 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG	IS-JH-DSH450237M	9/13/2012 2:00 PM
Details	Last Recertification Date	Insert				9/11/2012 6:03 PM
Details	Grant Number	Insert				9/11/2012 6:03 PM
Details	340B ID	Insert			OUTPATIENT_ONLINE_REG	9/11/2012 6:03 PM
Details	Is Authorizing Official EHB Data	Insert				9/11/2012 6:03 PM
Dates	Last Date That 340B Drugs Purchased	Insert				9/11/2012 6:03 PM
Details	Medicare Provider Number	Insert			450237	9/11/2012 6:03 PM
Details	Entity Name	Insert			CHRISTUS SANTA ROSA HEALTH SYSTEM	9/11/2012 6:03 PM
Details	Program Code	Insert			DSH	9/11/2012 6:03 PM
Details	Entity Subname	Insert			CHRISTUS Santa Rosa Wound Care	9/11/2012 6:03 PM
Dates	Participating Approval Date	Insert				9/11/2012 6:03 PM
Details	State	Insert			Pending	9/11/2012 6:03 PM
Dates	Registration Date	Insert			9/11/2012 12:00:00 AM	9/11/2012 6:03 PM
Dates	Signed By Date	Insert			9/11/2012 12:00:00 AM	9/11/2012 6:03 PM
Dates	Start Date	Insert				9/11/2012 6:03 PM
Terminations	Termination Comments	Insert				9/11/2012 6:03 PM
Terminations	Termination Date	Insert				9/11/2012 6:03 PM
Terminations	Termination Effective Date	Insert				9/11/2012 6:03 PM
Terminations	Termination Reason	Insert				9/11/2012 6:03 PM