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Payor

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Payor:
Client Payor #:
Status:	Inactive Active

Address 1:
Address 2:
Address 3:
City:
State/Province:
ZIP/Postal:
Country:

E-mail:
Phone:
Fax:

Payor Supplier Code:
AP1 Supplier Code:
AVP Supplier Code:
DVD1 Supplier Code:

Tax ID:

Display Logo:	Yes No

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