Covered Entity Details

DSH190098AM University Health Shreveport, LLC (Active) - information as of 6/28/2025 12:23:38 AM

Main Details

Name

University Health Shreveport, LLC

Subdivision Name

Med Specialty Clinic OLSP KH07 / SHV MED ENDOCRINOLOGY CLN

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH190098AM

Medicare Provider Number

190098

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/13/2016

Participating Start Date

7/1/2016

Participating Approval Date

4/29/2016

Last Recertification Date

9/5/2024

Contacts

Authorizing Official

Ochsner LSU
Christopher Eric Mangin, CEO
(318) 205-2245

Primary Contact

BRFHH Shreveport LLC
Jason D Lafitte, Director of Pharmacy
(318) 626-0863

Addresses

Street Address

1606 KINGS HIGHWAY
Ochsner LSU Health Shreveport-AMBULATORY CARE CENTE
SHREVEPORT, LA 71103-4128

Billing Address
Same as Street Address

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
LA	1737712	1427536325
AR	211064105	1427536325
OK	200601960A	1427536325
TX	344999301,344999302	1427536325

Shipping Addresses

Same as Street Address

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
DSH190098AA	Child	DSH	University Health Shreveport, LLC	Maternal Fetal Med OLSP KH02 / SHV CHC NEONATAL HI RK	1602 KINGS HIGHWAY	SHREVEPORT	LA	Terminated
DSH190098AB	Child	DSH	University Health Shreveport, LLC	Childrens Health OLSP KH06 / ACC Pediatrics	1602 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AC	Child	DSH	University Health Shreveport, LLC	Childrens Health OLSP KH06 / SHV CHC INFECT DISEASE	1602 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AD	Child	DSH	University Health Shreveport, LLC	Childrens Health OLSP KH06 / SHV CHC GENETICS	1602 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AE	Child	DSH	University Health Shreveport, LLC	Gastroenterology OLSP KH02 / OLSC Pediatric Gastroenterology	1602 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AF	Child	DSH	University Health Shreveport, LLC	Childrens Health OLSP KH06 / SHV CHC ALLERGY CLN	1602 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AG	Child	DSH	University Health Shreveport, LLC	Med Specialty Clinic OLSP KH07 / SHV MED RHEUMA CLN	1606 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AH	Child	DSH	University Health Shreveport, LLC	Med Specialty Clinic OLSP KH07 / SHV MED PULMONARY CLN	1606 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AJ	Child	DSH	University Health Shreveport, LLC	Med Specialty Clinic OLSP KH07 / SHV MED NEPHROLOGY CLN	1606 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AK	Child	DSH	University Health Shreveport, LLC	Med Specialty Clinic OLSP KH07 / SHV MED INFECT DIS CLN	1606 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AL	Child	DSH	University Health Shreveport, LLC	Gastroenterology OLSP KH02 / OLSC Gastroenterology	1606 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AM	Child	DSH	University Health Shreveport, LLC	Med Specialty Clinic OLSP KH07 / SHV MED ENDOCRINOLOGY CLN	1606 KINGS HIGHWAY	SHREVEPORT	LA	Active
DSH190098AN	Child	DSH	University Health Shreveport, LLC	Ochsner LSU Health Shreveport/ SHV MED DERM CLN	1606 KINGS HIGHWAY	SHREVEPORT	LA	Terminated
DSH190098AP	Child	DSH	University Health Shreveport, LLC	Cardiology Clinic OLSP KH11 - OLSH DCI NON-INVASIVE CARDIOLOGY	1320 KINGS HIGHWAY #200	SHREVEPORT	LA	Active
DSH190098AQ	Child	DSH	University Health Shreveport, LLC	MPP Gastro OLSP FA01 / MPP - Gastro Clinic	1801 FAIRFIELD AVE	SHREVEPORT	LA	Active
DSH190098AR	Child	DSH	University Health Shreveport, LLC	University Neurosurg OLSP MP02 / NEU - University Neurosurgery Clinic	911 Margaret Place	SHREVEPORT	LA	Active
DSH190098AS	Child	DSH	University Health Shreveport, LLC	OLHS Allergy and ENT OLSP AR01 - Allergy and ENT Clinic - Ashley Ridge	463 Ashley Ridge Boulevard	Shreveport	LA	Active
DSH190098AT	Child	DSH	University Health Shreveport, LLC	Primary Care OLSP FA03 - Primary Care - Fern Avenue	6841 Fern Avenue	Shreveport	LA	ToBeTerminated
DSH190098AU	Child	DSH	University Health Shreveport, LLC	Ortho & Sports Med OLSP OS01 - Olive Orthopedics and Sports Medicine Clinic	950 Olive Street	Shreveport	LA	Active
DSH190098AV	Child	DSH	University Health Shreveport, LLC	Primary Care OLSP SV02 - Primary Care - St Vincent	6670 St. Vincent Avenue	Shreveport	LA	Active
DSH190098AW	Child	DSH	University Health Shreveport, LLC	Opthalmology Clinic OLSP KH04 / OLSC ACC OPHTHALMOLOGY - ACC Opthalmology	1606 Kings Highway	Shreveport	LA	Active
DSH190098AX	Child	DSH	University Health Shreveport, LLC	Echo Lab OLSH KH02 / OLSH DCI ECHOCARDIOGRAPHY - ECHOCARDIOGRAPHY	1322 Kings Highway	Shreveport	LA	Active
DSH190098AY	Child	DSH	University Health Shreveport, LLC	Operating Room OLSH KH02 / OLSH FWCC OR PERIOP SERVICES - FWCC Periop	1405 Kings Highway	Shreveport	LA	Active
DSH190098AZ	Child	DSH	University Health Shreveport, LLC	Mammography OLSH KH02 / OLSH FWCC MAMMOGRAPHY - FWCC Mammography	1405 Kings Highway	Shreveport	LA	Active
DSH190098B	Child	DSH	BRFHH Shreveport LLC	Endoscopy Clinic	1541 Kings Highway	Shreveport	LA	Terminated
DSH190098BA	Child	DSH	University Health Shreveport, LLC	Diagnostic Imaging OLSH KH02 / OLSH OLIVE ORTHOPEDICS XRAY - Olive Ortho XRay	950 Olive Street	Shreveport	LA	Active
DSH190098BB	Child	DSH	University Health Shreveport, LLC	Nuclear Medicine OLSH KH02 / OLSH DCI NUCLEAR MEDICINE - Nuclear Medicine	1322 Kings Highway	Shreveport	LA	Active
DSH190098BC	Child	DSH	University Health Shreveport, LLC	FWCC Infusion OLSH KH03 / OLSH FWCC CHEMOTHERAPY INFUSION - FWCC Infusion	1405 Kings Highway	Shreveport	LA	Active
DSH190098BD	Child	DSH	University Health Shreveport, LLC	Phlebotomy OLSH KH02 / OLSH FWCC LABORATORY 1ST FLOOR - FWCC Phlebotomy	1405 Kings Highway	Shreveport	LA	Active
DSH190098BE	Child	DSH	University Health Shreveport, LLC	Physical Therapy OLSH KH02 / OLSC OLIVE REHAB OUTPATIENT SERVICES - Olive OP Rehab	950 Olive Street	Shreveport	LA	Active
DSH190098BF	Child	DSH	University Health Shreveport, LLC	Provenance Int Med OLSP PP03 - OLSC PRV PRIMARY CARE	1023 Provenance Place	Shreveport	LA	Approved
DSH190098BG	Child	DSH	University Health Shreveport, LLC	Peds Endocrinology OLHP KH06 - OLSC ACC PEDIATRIC ENDOCRINOLOGY	1606 Kings Highway	Shreveport	LA	Approved
DSH190098BH	Child	DSH	University Health Shreveport, LLC	Peds Specialities OLSP KH06 - OLSC ACC PEDIATRIC INFECTIOUS DISEASE	1606 Kings Highway	Shreveport	LA	Approved
DSH190098BJ	Child	DSH	University Health Shreveport, LLC	Neurology OLSP KH07 - OLSC FF NEUROLOGY	1801 Fairfield Avenue	Shreveport	LA	Approved
DSH190098BK	Child	DSH	University Health Shreveport, LLC	Audiology OLSH KH02 - OLSH ACC AUDIOLOGY	1606 Kings Highway	Shreveport	LA	Approved
DSH190098BL	Child	DSH	University Health Shreveport, LLC	Phlebotomy OLSH KH02 - OLSH ACC LABORATORY - 1ST FLOOR	1606 Kings Highway	Shreveport	LA	Approved
DSH190098BM	Child	DSH	University Health Shreveport, LLC	ACC Radiology OLSH KH07 - OLSH ACC XRAY	1606 Kings Highway	Shreveport	LA	Approved
DSH190098BN	Child	DSH	University Health Shreveport, LLC	FWCC Radiology OLSH KH03 - OLSH FWCC CT SCAN	1405 Kings Highway	Shreveport	LA	Approved
DSH190098BP	Child	DSH	University Health Shreveport, LLC	PACU OLSH KH02 - OLSH FWCC OR PRE/POST OP	1405 Kings Highway	Shreveport	LA	Approved
DSH190098BQ	Child	DSH	University Health Shreveport, LLC	Prescott GYN OLSP JA01 - OLSC JW OBSTETRICS AND GYNECOLOGY	3810 Jewella Avenue	Shreveport	LA	Approved
DSH190098BR	Child	DSH	University Health Shreveport, LLC	CTC Infusion OLSH BK06 - OLSH 301BK CHEMOTHERAPY INFUSION	301 Bert Kouns Industrial Loop	Shreveport	LA	Approved
DSH190098C	Child	DSH	BRFHH Shreveport LLC	Childrens Health Clinic	1602 Kings Highway	Shreveport	LA	Terminated
DSH190098D	Child	DSH	University Health Shreveport, LLC	HIV Clinic OLSP KH10 / HIV Clinic	1606 Kings Highway	Shreveport	LA	Active
DSH190098E	Child	DSH	University Health Shreveport, LLC	Ochsner LSU Health Shreveport/Diabetic and Wound Clinic	1606 Kings Highway	Shreveport	LA	Terminated
DSH190098F	Child	DSH	University Health Shreveport, LLC	Ochsner LSU Health Shreveport/Comp Care Clinic	1541 Kings Highway	Shreveport	LA	Terminated
DSH190098G	Child	DSH	University Health Shreveport, LLC	Family Practice Clin OLSP KH02 / Family Practice Clinic	1541 Kings Highway	Shreveport	LA	Active
DSH190098H	Child	DSH	BRFHH Shreveport LLC	Sickle Cell Clinic	1405 Kings Highway	Shreveport	LA	Terminated
DSH190098J	Child	DSH	University Health Shreveport, LLC	Neurology OLSP KH07 / Neurology Clinic	911 Margaret Place	Shreveport	LA	Active
DSH190098K	Child	DSH	University Health Shreveport, LLC	Ophthalmology Clinic OLSP KH04 / Ophthalmology Clinic	1420 Kings Highway	Shreveport	LA	Active
DSH190098L	Child	DSH	University Health Shreveport, LLC	ENT Clinic OLSP KH02 / ENT Clinic	1606 Kings Highway	Shreveport	LA	Active
DSH190098M	Child	DSH	University Health Shreveport, LLC	Surgery Clinic OLSP KH02 / Surgery Clinic	1606 Kings Highway	Shreveport	LA	Active
DSH190098N	Child	DSH	University Health Shreveport, LLC	FW Adult Hematology OLSP KH03 / Hematology Clinic	1405 Kings Highway	Shreveport	LA	Active
DSH190098P	Child	DSH	University Health Shreveport, LLC	FW Peds Oncology OLSP KH03 / FW Peds Oncology Clinic	1405 Kings Highway	Shreveport	LA	Active
DSH190098Q	Child	DSH	University Health Shreveport, LLC	FW Surgery Oncology OLSP KH03/FW Surgery Oncology Clinic	1405 Kings Highway	Shreveport	LA	Active
DSH190098R	Child	DSH	University Health Shreveport, LLC	Orthopedic Clinic OLSP KH02 / Orthopedic Clinic	1606 Kings Highway	Shreveport	LA	Active
DSH190098S	Child	DSH	University Health Shreveport, LLC	Perinatal Center OLSP KH02 / ACC Maternal Fetal Medicine	1606 Kings Highway	Shreveport	LA	Terminated
DSH190098T	Child	DSH	University Health Shreveport, LLC	OB GYN Clinic OLSP KH02 / GYN Clinic	1602 Kings Highway	Shreveport	LA	Active
DSH190098U	Child	DSH	University Health Shreveport, LLC	Urology Clinic OLSP KH02 / Urology Clinic	1606 Kings Highway	Shreveport	LA	Active
DSH190098V	Child	DSH	BRFHH Shreveport LLC	Medicine Specialty Clinic	1606 Kings Highway	Shreveport	LA	Terminated
DSH190098W	Child	DSH	University Health Shreveport, LLC	Maxillofacial Surg OLSP KH02 / Oral Maxillofacial Surgery	1606 Kings Highway	Shreveport	LA	Active
DSH190098X	Child	DSH	University Health Shreveport, LLC	General Med Clinic OLSP KH07/Medicine Clinic	1606 Kings Highway	Shreveport	LA	Active
DSH190098Y	Child	DSH	University Health Shreveport, LLC	Psychiatric Clinic OLSP KH07 / Psychiatric Clinic	1606 Kings Highway	Shreveport	LA	Active
DSH190098Z	Child	DSH	University Health Shreveport, LLC	Childrens Health OLSP KH06 / SHV CHC PULMONOLOGY	1602 KINGS HIGHWAY	SHREVEPORT	LA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Medicaid Billing	NPI: Number	Insert	Group Change Request		1427536325	1/14/2025 8:26 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		LA	1/14/2025 8:26 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1427536325	1/14/2025 8:26 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		AR	1/14/2025 8:26 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1427536325	1/14/2025 8:26 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		OK	1/14/2025 8:26 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1427536325	1/14/2025 8:26 AM
Medicaid Billing	NPI: State	Insert	Group Change Request		TX	1/14/2025 8:26 AM
Details	Last Recertification Date	Update	Recertification	8/15/2023 1:50:33 PM	9/5/2024 6:14:44 PM	9/5/2024 6:14 PM
Details	Last Recertification Date	Update	Recertification	9/8/2022 4:21:13 PM	8/15/2023 1:50:33 PM	8/15/2023 1:50 PM
Contacts	Authorizing Official	Update	Change Request	Walton, Lauri Chief Financial Officer Ochsner LSU Health Shreveport 3182124741	Mangin, Christopher Eric CEO Ochsner LSU 3182052245	5/1/2023 7:13 AM
Details	Last Recertification Date	Update	Recertification	9/13/2021 10:11:53 AM	9/8/2022 4:21:13 PM	9/8/2022 4:21 PM
Contacts	Authorizing Official	Update	Change Request	Moore, Vernon Chief Financial Officer Ochsner LSU Health Shreveport 3186260990	Walton, Lauri Chief Financial Officer Ochsner LSU Health Shreveport 3182124741	6/21/2022 6:45 AM
Details	Last Recertification Date	Update	Recertification	9/14/2020 6:39:31 AM	9/13/2021 10:11:53 AM	9/13/2021 10:11 AM
Details	Entity Subname	Update	Recertification	Ochsner LSU Health Shreveport / SHV MED ENDOCRINOLOGY CLN	Med Specialty Clinic OLSP KH07 / SHV MED ENDOCRINOLOGY CLN	9/13/2021 10:11 AM
Contacts	Authorizing Official	Update	Change Request	Randolph, Mark A CEO Ochsner LSU Health Monroe 3185842569	Moore, Vernon Chief Financial Officer Ochsner LSU Health Shreveport 3186260990	9/24/2020 2:58 PM
Details	Entity Name	Update	Recertification	BRFHH Shreveport LLC	University Health Shreveport, LLC	9/16/2020 7:11 AM
Addresses	Main Address	Update	Recertification	1606 KINGS HIGHWAY UNIVERSITY HEALTH SHREVEPORT-AMBULATORY CARE CENTE SHREVEPORT, LA 71103-4128	1606 KINGS HIGHWAY Ochsner LSU Health Shreveport-AMBULATORY CARE CENTE SHREVEPORT, LA 71103-4128	9/14/2020 6:39 AM
Details	Last Recertification Date	Update	Recertification	9/16/2019 8:19:00 PM	9/14/2020 6:39:31 AM	9/14/2020 6:39 AM
Details	Entity Subname	Update	Recertification	BRFHH SHREVEPORT LLC / SHV MED ENDOCRINOLOGY CLN	Ochsner LSU Health Shreveport / SHV MED ENDOCRINOLOGY CLN	9/14/2020 6:39 AM
Contacts	Authorizing Official	Update	Profile Change Request	Randolph, Mark A Chief Operating Officer BRFHH Shreveport LLC 3186260974	Randolph, Mark A CEO Ochsner LSU Health Monroe 3185842569	7/14/2020 4:54 PM
Contacts	Primary Contact	Update	Recertification	Lafitte, Jason Director of Pharmacy BRFHH Shreveport LLC dba University Health Shreveport 3186260863	Lafitte, Jason D Director of Pharmacy BRFHH Shreveport LLC 3186260863	9/16/2019 8:19 PM
Details	Last Recertification Date	Update	Recertification	8/23/2018 7:39:44 PM	9/16/2019 8:19:00 PM	9/16/2019 8:19 PM
Contacts	Authorizing Official	Update	AO Change Request	Randolph, Mark President University Health Shreveport 3186260982	Randolph, Mark A Chief Operating Officer BRFHH Shreveport LLC 3186260974	8/15/2019 7:04 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 6:18:01 PM	8/23/2018 7:39:44 PM	8/23/2018 7:39 PM
Details	Entity Name	Update	Recertification	UNIVERSITY HEALTH SHREVEPORT	BRFHH Shreveport LLC	11/15/2017 9:23 PM
Details	Last Recertification Date	Update	Recertification	8/17/2016 12:00:00 AM	11/9/2017 6:18:01 PM	11/9/2017 6:18 PM
Contacts	Authorizing Official	Update	Profile Change Request	Randolph, Mark Chief Operating Officer University Health Shreveport 3186260982	Randolph, Mark President University Health Shreveport 3186260982	10/6/2017 10:03 PM
Contacts	Signed By	Update	Profile Change Request	Randolph, Mark Chief Operating Officer University Health Shreveport 3186260982	Randolph, Mark President University Health Shreveport 3186260982	10/6/2017 10:03 PM
Contacts	Authorizing Official	Update		Randolph, Mark Chief Operating Officer 3186260982	Randolph, Mark Chief Operating Officer University Health Shreveport 3186260982	10/6/2017 9:59 PM
Contacts	Signed By	Update		Randolph, Mark Chief Operating Officer 3186260982	Randolph, Mark Chief Operating Officer University Health Shreveport 3186260982	10/6/2017 9:59 PM
Contacts	Primary Contact	Update		Lafitte, Jason Director of Pharmacy 3186260863	Lafitte, Jason Director of Pharmacy BRFHH Shreveport LLC dba University Health Shreveport 3186260863	9/29/2017 9:02 AM
Contacts	Primary Contact	Insert			Lafitte, Jason Director of Pharmacy 3186260863	4/17/2017 7:28 PM
Contacts	Authorizing Official	Insert			Randolph, Mark Chief Operating Officer 3186260982	4/17/2017 7:28 PM
Contacts	Signed By	Insert			Randolph, Mark Chief Operating Officer 3186260982	4/17/2017 7:28 PM
Addresses	Main Address	Insert			1606 KINGS HIGHWAY UNIVERSITY HEALTH SHREVEPORT-AMBULATORY CARE CENTE SHREVEPORT, LA 71103-4128	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: Number	Insert			211064105	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: State	Insert			AR	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: Number	Insert			200601960A	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: State	Insert			OK	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: Number	Insert			344999301	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: State	Insert			TX	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: Is Primary	Insert			False	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: Number	Insert			344999302	8/17/2016 3:27 PM
Medicaid Billing	Medicaid: State	Insert			TX	8/17/2016 3:27 PM
Details	Last Recertification Date	Update			8/17/2016 12:00:00 AM	8/17/2016 3:27 PM
Dates	Participating Approval Date	Update			4/29/2016 12:00:00 AM	4/29/2016 7:01 PM
Details	State	Update		Pending	Active	4/29/2016 7:01 PM
Dates	Start Date	Update			7/1/2016 12:00:00 AM	4/29/2016 7:01 PM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_59985	DSH190098AM	4/20/2016 2:54 PM
Details	Entity Subname	Update		BRFHH SHREVEPORT LLC / SHV MED END CLN	BRFHH SHREVEPORT LLC / SHV MED ENDOCRINOLOGY CLN	4/20/2016 2:54 PM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_59985	4/13/2016 11:17 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/13/2016 11:17 AM
Medicaid Billing	Medicaid: Number	Insert			1737712	4/13/2016 11:17 AM
Medicaid Billing	Medicaid: State	Insert			LA	4/13/2016 11:17 AM
Details	Last Recertification Date	Insert				4/13/2016 11:17 AM
Details	Grant Number	Insert				4/13/2016 11:17 AM
Details	340B ID	Insert				4/13/2016 11:17 AM
Details	Is Authorizing Official EHB Data	Insert				4/13/2016 11:17 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/13/2016 11:17 AM
Details	Medicare Provider Number	Insert			190098	4/13/2016 11:17 AM
Details	Entity Name	Insert			UNIVERSITY HEALTH SHREVEPORT	4/13/2016 11:17 AM
Details	Program Code	Insert			DSH	4/13/2016 11:17 AM
Details	Entity Subname	Insert			BRFHH SHREVEPORT LLC / SHV MED END CLN	4/13/2016 11:17 AM
Dates	Participating Approval Date	Insert				4/13/2016 11:17 AM
Details	State	Insert			Pending	4/13/2016 11:17 AM
Dates	Registration Date	Insert			4/13/2016 12:00:00 AM	4/13/2016 11:17 AM
Dates	Signed By Date	Insert			4/13/2016 12:00:00 AM	4/13/2016 11:17 AM
Dates	Start Date	Insert				4/13/2016 11:17 AM
Terminations	Termination Comments	Insert				4/13/2016 11:17 AM
Terminations	Termination Date	Insert				4/13/2016 11:17 AM
Terminations	Termination Effective Date	Insert				4/13/2016 11:17 AM
Terminations	Termination Reason	Insert				4/13/2016 11:17 AM