Provider Demographics
NPI:1083006720
Name:ELDERHAUS INN #19, LLC
Entity Type:Organization
Organization Name:ELDERHAUS INN #19, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:ILMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANWAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-792-5777
Mailing Address - Street 1:4 CLAYTON COURT DR
Mailing Address - Street 2:
Mailing Address - City:FRONTENAC
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2524
Mailing Address - Country:US
Mailing Address - Phone:314-792-5777
Mailing Address - Fax:
Practice Address - Street 1:125 ANNA AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MO
Practice Address - Zip Code:63379-2402
Practice Address - Country:US
Practice Address - Phone:314-792-5777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC001429138310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility