Provider Demographics
NPI:1073843033
Name:CJM ELDERHEALTH, LLC
Entity Type:Organization
Organization Name:CJM ELDERHEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTICIONER
Authorized Official - Prefix:
Authorized Official - First Name:CANDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS-MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:314-324-3401
Mailing Address - Street 1:415 GLENMEADOW DR
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-3466
Mailing Address - Country:US
Mailing Address - Phone:636-566-8155
Mailing Address - Fax:
Practice Address - Street 1:415 GLENMEADOW DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-3466
Practice Address - Country:US
Practice Address - Phone:636-566-8155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO088713363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA2295Medicare PIN