B. The authorized delegate report shall include the following information for each authorized delegate:
1. The company legal name.
2. The taxpayer employer identification number.
3. The principal provider identifier.
4. The physical address, if any.
5. The mailing address.
6. Any business conducted in other states.
7. Any fictitious or trade name.
8. The contact person name, telephone number and email address.
9. The start date as the licensee's authorized delegate.
10. The end date as the licensee's authorized delegate, if applicable.
11. Any other information the director reasonably requires with respect to the authorized delegate.