Covered Entity Details

DSH230021M LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS (Active) - information as of 5/20/2025 11:45:19 PM

Main Details

Name

LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS

Subdivision Name

CT Scanner - Niles

Type

Disproportionate Share Hospital

Rural

340B ID

DSH230021M

Medicare Provider Number

230021

Outpatient Facility Provider Number

Additional Details

Current Program Status

Active

Registration Date

4/5/2017

Participating Start Date

7/1/2017

Participating Approval Date

4/26/2017

Last Recertification Date

8/20/2024

Contacts

Authorizing Official

Corewell Health
Hardik Dalal, SVP, Finance & System-wide Pharmacy Finance
(312) 771-0810

Primary Contact

Lakeland Regional Health DBA Corewell Health
Nicole Weston, Business Analyst
(269) 985-4431

Addresses

Street Address

31 N St Joseph Avenue
Niles, MI 49120

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
MI	5171314,1555548	1134220031

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
DSH230021A	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH	LAKELAND MEDICAL CENTER NILES	31 N ST JOSEPH AVENUE	NILES	MI	Terminated
DSH230021AA	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Endoscopy - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021AB	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH	Ambulatory Surgery - COPS	3900 Hollywood Rd	St Joseph	MI	Terminated
DSH230021AC	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Operating Room - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021AD	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Labor and Delivery - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021AE	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	ICU - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021AF	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Obstetrics - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021AG	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Medical/Surgical - Niles A2/A3	31 N St Joseph Avenue	Niles	MI	Active
DSH230021AH	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH	Lakeland Cardiology Niles - Cardiology	61 N. St. Joseph Avenue	Niles	MI	Terminated
DSH230021AJ	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Niles EEG - Neurology	31 N. St. Joseph Avenue	Niles	MI	Active
DSH230021AK	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Niles Recovery - Surgery	31 N. St. Joseph Avenue	Niles	MI	Terminated
DSH230021AL	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH	Home Care Niles - Home Care	2 N. St. Joseph Avenue	Niles	MI	Terminated
DSH230021AM	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	LAKELAND CANCER SPECIALISTS NILES - LCSP CANCER SPECIALISTS NILES	42 N. St. Joseph Avenue	NILES	MI	Active
DSH230021AN	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	LAKELAND CANCER SPECIALISTS ST JOSEPH - LCSP CANCER SPECIALISTS ST JOE	3900 HOLLYWOOD ROAD	SAINT JOSEPH	MI	Active
DSH230021AP	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	COPS - Sleep Diagnostic Practice	3950 Hollywood Rd	St Joseph	MI	Active
DSH230021AQ	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	COPS - Neurology Practice	3950 Hollywood Rd	St Joseph	MI	Active
DSH230021AR	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	COPS - Infectious Disease Practice	3950 Hollywood Rd	St Joseph	MI	Active
DSH230021AS	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	COPS - Rheumatology Practice	3950 Hollywood Rd	St Joseph	MI	Active
DSH230021AT	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	COPS - Diabetes and Endocrinology Practice	3950 Hollywood Rd	St Joseph	MI	Active
DSH230021AU	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Watervliet - Infusion Clinic	400 Medical Park Dr	Watervliet	MI	Active
DSH230021AV	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	COREWELL HEALTH LAKELAND HOSPITALS - Gastroenterology Practice	3903 HOLLYWOOD RD	ST. JOSEPH	MI	Approved
DSH230021B	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH	LAKELAND CENTER FOR OUTPATIENT SERVICES - ST JOSEPH	3900 HOLLYWOOD ROAD	ST JOSEPH	MI	Terminated
DSH230021C	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	LAKELAND ONCOLOGY CLINIC	3900 HOLLYWOOD ROAD	ST JOSEPH	MI	Terminated
DSH230021D	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH	LAKELAND HOMECARE	2550 MEADOWBROOK RD	BENTON HARBOR	MI	Terminated
DSH230021E	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM	Lakeland Home Infusion	2550 Meadowbrook Road	Benton Harbor	MI	Terminated
DSH230021F	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Respiratory Therapy - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021G	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Anesthesiology - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021H	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Cardiology and EKG - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021J	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Ultrasound - COPS	3900 Hollywood Road	St Joseph	MI	Active
DSH230021K	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Ultrasound - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021L	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	CT Scanner - COPS	3900 Hollywood Road	St Joseph	MI	Active
DSH230021M	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	CT Scanner - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021N	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	MRI - COPS	3900 Hollywood Road	St Joseph	MI	Active
DSH230021P	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Nuclear Medicine - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021Q	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	MRI - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021R	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	PET Scan - COPS	3900 Hollywood Road	St Joseph	MI	Active
DSH230021S	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Radiology - COPS	3900 Hollywood Road	St Joseph	MI	Active
DSH230021T	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Radiology - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021U	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Sleep Lab - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021V	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Laboratroy - Niles	31 N St Joseph Avenue	Niles	MI	Terminated
DSH230021W	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	LAKELAND CENTER FOR WOUND CARE AND	42 N SAINT JOSEPH AVE	NILES	MI	Active
DSH230021X	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Ambulatory Infusion - Niles	42 N St Joseph Avenue Suite 303	Niles	MI	Terminated
DSH230021Y	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Chest Pain Unit - Niles	31 N St Joseph Avenue	Niles	MI	Active
DSH230021Z	Child	DSH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	Emergency Roon - Niles	31 N St Joseph Avenue	Niles	MI	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Contacts	Authorizing Official	Update	Profile Change Request	Dalal, Hardik SVP, Finance CHW Corewell Health 3127710810	Dalal, Hardik SVP, Finance & System-wide Pharmacy Finance Corewell Health 3127710810	2/24/2025 6:26 AM
Details	Last Recertification Date	Update	Recertification	8/30/2023 9:15:55 AM	8/20/2024 4:50:31 PM	8/20/2024 4:50 PM
Contacts	Primary Contact	Update	PC Change Request	Taylor, Michael Analyst Business Intell. Spectrum Health 2692628670	Weston, Nicole Business Analyst Lakeland Regional Health DBA Corewell Health 2699854431	8/9/2024 11:51 AM
Contacts	Authorizing Official	Update	Change Request	Baggio, Natalie Sr VP Clinical Operations Corewell Health 2178258212	Dalal, Hardik SVP, Finance CHW Corewell Health 3127710810	2/20/2024 8:08 AM
Contacts	Primary Contact	Update	Profile Change Request	Taylor, Michael 340B Coordinator Spectrum Health 2692628670	Taylor, Michael Analyst Business Intell. Spectrum Health 2692628670	12/27/2023 9:35 AM
Details	Entity Name	Update	Change Request	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH DBA COREWELL HEALTH LAKELAND HOSPITALS	9/28/2023 8:53 AM
Details	Last Recertification Date	Update	Recertification	8/26/2022 10:26:11 AM	8/30/2023 9:15:55 AM	8/30/2023 9:15 AM
Contacts	Primary Contact	Update	PC Change Request	Taylor, Michael James 340B Coordinator Lakeland Regional Health 2692628670	Taylor, Michael 340B Coordinator Spectrum Health 2692628670	7/10/2023 7:05 AM
Contacts	Authorizing Official	Update	AO Change Request	Baggio, Natalie SVP, Patient Care Services CNE LKD Lakeland Regional Health 2178258212	Baggio, Natalie Sr VP Clinical Operations Corewell Health 2178258212	6/16/2023 8:39 AM
Contacts	Authorizing Official	Update	Change Request	Konopacki, Paul Vincent VP Finance & CFO Spectrum Health 2693137188-2693137188	Baggio, Natalie SVP, Patient Care Services CNE LKD Lakeland Regional Health 2178258212	12/16/2022 6:58 AM
Details	Last Recertification Date	Update	Recertification	8/19/2021 12:22:25 PM	8/26/2022 10:26:11 AM	8/26/2022 10:26 AM
Details	Last Recertification Date	Update	Recertification	8/20/2020 1:24:34 PM	8/19/2021 12:22:25 PM	8/19/2021 12:22 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	100275530A (IN)		6/10/2021 12:03 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	382156872002 (IL)		6/10/2021 12:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1134220031 (IN)		6/10/2021 12:03 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1134220031 (IL)		6/10/2021 12:03 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1134220031	10/12/2020 4:53 PM
Medicaid Billing	NPI: State	Insert	Change Request		IN	10/12/2020 4:53 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1134220031	10/12/2020 4:53 PM
Medicaid Billing	NPI: State	Insert	Change Request		IL	10/12/2020 4:53 PM
Contacts	Primary Contact	Update	Change Request	TAYLOR, MICHAEL J. 340B COORDINATOR Lakeland Health 2696871877	Taylor, Michael James 340B Coordinator Lakeland Regional Health 2692628670	9/10/2020 1:17 PM
Medicaid Billing	NPI: State	Update	Recertification		MI	8/20/2020 1:24 PM
Details	Last Recertification Date	Update	Recertification	8/21/2019 7:15:11 AM	8/20/2020 1:24:34 PM	8/20/2020 1:24 PM
Contacts	Authorizing Official	Update	AO Change Request	CALHOUN, TIM CFO Lakeland Hospitals 2699838398	Konopacki, Paul Vincent VP Finance & CFO Spectrum Health 2693137188-2693137188	6/9/2020 3:05 PM
Details	Entity Name	Update	Change Request	LAKELAND REGIONAL HEALTH SYSTEM	LAKELAND REGIONAL HEALTH SYSTEM LAKELAND MEDICAL CENTER ST JOSEPH	3/17/2020 10:38 AM
Details	Last Recertification Date	Update	Recertification	8/16/2018 7:59:26 AM	8/21/2019 7:15:11 AM	8/21/2019 7:15 AM
Contacts	Primary Contact	Update	Profile Change Request	TAYLOR, MICHAEL J. 340B COORDINATOR Lakeland Health 2699854509	TAYLOR, MICHAEL J. 340B COORDINATOR Lakeland Health 2696871877	7/15/2019 7:29 AM
Details	Last Recertification Date	Update	Recertification	11/9/2017 8:03:16 AM	8/16/2018 7:59:26 AM	8/16/2018 7:59 AM
Details	Last Recertification Date	Update	Recertification	10/26/2017 7:45:23 AM	11/9/2017 8:03:16 AM	11/9/2017 8:03 AM
Details	Entity Name	Update	Recertification	LAKELAND MEDICAL CENTER ST. JOSEPH	LAKELAND REGIONAL HEALTH SYSTEM	11/9/2017 7:59 AM
Details	Last Recertification Date	Update	Recertification		10/26/2017 7:45:23 AM	10/26/2017 7:45 AM
Contacts	Authorizing Official	Update		CALHOUN, TIM CFO 2699838398	CALHOUN, TIM CFO Lakeland Hospitals 2699838398	9/28/2017 12:42 PM
Contacts	Signed By	Update		CALHOUN, TIM CFO 2699838398	CALHOUN, TIM CFO Lakeland Hospitals 2699838398	9/28/2017 12:42 PM
Contacts	Primary Contact	Update		TAYLOR, MICHAEL J. 340B COORDINATOR 2699854509	TAYLOR, MICHAEL J. 340B COORDINATOR Lakeland Health 2699854509	9/25/2017 12:53 PM
Contacts	Primary Contact	Insert			TAYLOR, MICHAEL J. 340B COORDINATOR 2699854509	8/2/2017 10:12 AM
Contacts	Authorizing Official	Insert			CALHOUN, TIM CFO 2699838398	8/2/2017 10:12 AM
Contacts	Signed By	Insert			CALHOUN, TIM CFO 2699838398	8/2/2017 10:12 AM
Addresses	Main Address	Insert			31 N St Joseph Avenue Niles, MI 49120	6/23/2017 6:59 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/23/2017 6:58 AM
Medicaid Billing	Medicaid: Number	Insert			1555548	6/23/2017 6:58 AM
Medicaid Billing	Medicaid: State	Insert			MI	6/23/2017 6:58 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/20/2017 11:25 AM
Medicaid Billing	Medicaid: Number	Insert			100275530A	6/20/2017 11:25 AM
Medicaid Billing	Medicaid: State	Insert			IN	6/20/2017 11:25 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	6/20/2017 11:25 AM
Medicaid Billing	Medicaid: Number	Insert			382156872002	6/20/2017 11:25 AM
Medicaid Billing	Medicaid: State	Insert			IL	6/20/2017 11:25 AM
Dates	Participating Approval Date	Update			4/26/2017 12:00:00 AM	4/26/2017 11:29 AM
Details	State	Update		Pending	Active	4/26/2017 11:29 AM
Dates	Start Date	Update			7/1/2017 12:00:00 AM	4/26/2017 11:29 AM
Details	340B ID	Update		OUTPATIENT_ONLINE_REG_75965	DSH230021M	4/6/2017 10:46 AM
Details	340B ID	Update			OUTPATIENT_ONLINE_REG_75965	4/5/2017 11:28 AM
Medicaid Billing	Medicaid: Is Primary	Insert			False	4/5/2017 11:28 AM
Medicaid Billing	Medicaid: Number	Insert			5171314	4/5/2017 11:28 AM
Medicaid Billing	Medicaid: State	Insert			MI	4/5/2017 11:28 AM
Medicaid Billing	NPI: Number	Insert			1134220031	4/5/2017 11:28 AM
Details	Last Recertification Date	Insert				4/5/2017 11:28 AM
Details	Grant Number	Insert				4/5/2017 11:28 AM
Details	340B ID	Insert				4/5/2017 11:28 AM
Details	Is Authorizing Official EHB Data	Insert				4/5/2017 11:28 AM
Dates	Last Date That 340B Drugs Purchased	Insert				4/5/2017 11:28 AM
Details	Medicare Provider Number	Insert			230021	4/5/2017 11:28 AM
Details	Entity Name	Insert			LAKELAND MEDICAL CENTER ST. JOSEPH	4/5/2017 11:28 AM
Details	Program Code	Insert			DSH	4/5/2017 11:28 AM
Details	Entity Subname	Insert			CT Scanner - Niles	4/5/2017 11:28 AM
Dates	Participating Approval Date	Insert				4/5/2017 11:28 AM
Details	State	Insert			Pending	4/5/2017 11:28 AM
Dates	Registration Date	Insert			4/5/2017 12:00:00 AM	4/5/2017 11:28 AM
Dates	Signed By Date	Insert			4/5/2017 12:00:00 AM	4/5/2017 11:28 AM
Dates	Start Date	Insert				4/5/2017 11:28 AM
Terminations	Termination Comments	Insert				4/5/2017 11:28 AM
Terminations	Termination Date	Insert				4/5/2017 11:28 AM
Terminations	Termination Effective Date	Insert				4/5/2017 11:28 AM
Terminations	Termination Reason	Insert				4/5/2017 11:28 AM