Consumer Profile - PUEBLO
Consumer Profile - PUEBLO
Status
*
Active
Inactive
Term'd
Medicaid ID
*
Client Name
*
First
Last
Consumer Address
*
105 LEHIGH AVE PUEBLO CO 81003
Date of Birth
*
/
MM
/
DD
YYYY
Gender
*
Female
Male
CCB/P
*
CBE
IFI
TRE
XPS
Waiver
*
CES
DD
SLS
State
XPS
SIS
*
1 SIS
2 SIS
3 SIS
4 SIS
5 SIS
6 SIS
7 SIS
10 State
90 CES
99 XPS
Notes:
