1-800-717-9410
Provider Enrollment
Please fill in every space, if you do not have an answer,
please enter "No Answer"
Once this application is reviewed an EquityHealth Agent will contact
you to establish a your practice profile.
Practice Name
Practice website
Contact person
Job title:
Contact email
Address
Practice Address
Address line 2
Practice Phone #
Practice type or
specialty
Hours of Operation
List top 5 conditions this practice routinely treats
Briefly describe the practice and treatments available
