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GS*HS*52095*52095*250911*1409*1073904009*X*005010X279A1~
ST*270*000000572*005010X279A1~
BHT*0022*13*000000572*2509254*1409~
HL*1**20*1~
NM1*PR*2*KAISER MEDICAID*****PI*52095~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*PINEDA*JAN ANN ALEDRO****MI*21345844~
DMG*D8*19810112*F~
DTP*291*RD8*20250911-20251210~
EQ*42~
EQ*30~
SE*14*000000572~
GE*1*572~
IEA*1*000000572~