Molina Medicaid Solutions - DHHR

exv10w24Signatory Title CEO(Printed):HSA — Hospital Services AgreementSignature Date: 4/16/09Molina ECMS ref# 729 Provider or authorizedMHC v122706 / MHI v091707 representative’s initials:Pacific Hospital of Long BeachPage 19 of 40ATTACHMENT AProvider Identification Sheet (Continuation Page)Use one or more continuation pages as necessary when multiple providers under common ownership (the Provider is signing on behalf of all ofthem) are expected to bill Health Plan under more than one TIN and/or billing address. Please enter “N/A” for the following if not applicable or notavailable:Provider Name Billing Address:Telephone No. StreetFacsimile No. CityEmail Address State, Zip ,Tax I.D. No. Physical Address:License No. StreetNPI (or UPIN if NPINPI:Citynot yet designated)UPIN:DEA No. State, Zip ,Provider Name Billing Address:Telephone No. StreetFacsimile No. CityEmail Address State, Zip ,Tax I.D. No. Physical Address:License No. StreetNPI (or UPIN if NPINPI:Citynot yet designated)UPIN:DEA No. State, Zip ,Provider Name Billing Address:Telephone No. StreetFacsimile No. CityEmail Address State, Zip ,Tax I.D. No. Physical Address:License No. StreetNPI (or UPIN if NPINPI:Citynot yet designated)UPIN:DEA No. State, Zip ,Provider Name Billing Address:Telephone No. StreetFacsimile No. CityEmail Address State, Zip ,Tax I.D. No. Physical Address:http://sec.gov/Archives/edgar/data/1179929/000095012310025132/a55407exv10w24.htm[1/6/2012 11:13:06 AM]