| 45399-3 | Federal provider number:ID:Pt:Facility:Nom: | required |
| 52830-7 | State, district or territory federal abbreviation:Loc:Pt:Facility:Nom: | required |
| 52831-5 | Postal code Fclty | optional |
| 52829-9 | Place of service:Type:Pt:Facility:Nom: | required |
| 52832-3 | Survey reporting period start date:Date:Pt:Facility:Qn: | optional |
| 52833-1 | Survey reporting period end date:Date:Pt:Facility:Qn: | optional |
| 52828-1 | Federal provider name:ID:Pt:Facility:Nom: | optional |