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  2. 2015
  3. September
  4. R
  5. Rourke test
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Name of operation (dba)
   
 
 
 
Ownership name
   
 
 
 
Ownership structure #1
 
Private
 
Public
 
 
 
Ownership structure #2
 
Proprietary
 
Not for Profit
 
 
 
Ownership structure #3
 
Corporation
 
LLC
 
Other
 
 
 
 
Name and contact for System CEO
   
 
 
 
Name and contact for BH CEO/Administrator
   
 
 
 
Number of licensed BH beds
   
 
 
 
Capacity for OP program
 
 
 
Number of total beds licensed (if applicable)
 
1-20
 
21-40
 
41-60
 
Not Applicable
 
Other
 
 
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