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GS*HS*15004*15004*260501*1405*1073904009*X*005010X279A1~
ST*270*000002197*005010X279A1~
BHT*0022*13*000002197*2605121*1405~
HL*1**20*1~
NM1*PR*2*MEDICARE PPS*****PI*10000~
HL*2*1*21*1~
NM1*1P*2*GRACE HOME HEALTHCARE, LLC*****XX*1073904009~
HL*3*2*22*0~
NM1*IL*1*GRANT*MURIEL****MI*7Y19J87UV26~
DMG*D8*19470525*F~
DTP*291*RD8*20260501-20260730~
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IEA*1*000002197~