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GS*HS*10000*10000*260119*1001*1487113239*X*005010X279A1~
ST*270*000039113*005010X279A1~
BHT*0022*13*000039113*260119*1001~
HL*1**20*1~
NM1*PR*2*MEDICARE PPS*****PI*10000~
HL*2*1*21*1~
NM1*1P*2*HOMECENTRIS HEALTHCARE LLC*****XX*1487113239~
HL*3*2*22*0~
NM1*IL*1*STEVENSON*WILLIAM****MI*3FK4G78RP50~
DMG*D8*19580829*M~
DTP*291*RD8*20260119-20260419~
EQ*42~
EQ*30~
SE*14*000039113~
GE*1*39113~
IEA*1*000039113~