Provider Demographics
NPI:1609126838
Name:CAMBRIDGE AUDLT DAY CENTER MICHIGAN LLC
Entity Type:Organization
Organization Name:CAMBRIDGE AUDLT DAY CENTER MICHIGAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:ZERJAV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-932-1221
Mailing Address - Street 1:4249 MICHIGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111-1126
Mailing Address - Country:US
Mailing Address - Phone:314-932-1221
Mailing Address - Fax:314-932-1220
Practice Address - Street 1:4249 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111-1126
Practice Address - Country:US
Practice Address - Phone:314-932-1221
Practice Address - Fax:314-932-1220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1048261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1048Medicaid