Provider Demographics
NPI:1740560051
Name:CEJ SUPPLY LLC
Entity Type:Organization
Organization Name:CEJ SUPPLY LLC
Other - Org Name:CEJ SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:N
Authorized Official - Last Name:DAHLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-707-3796
Mailing Address - Street 1:2443 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2641
Mailing Address - Country:US
Mailing Address - Phone:208-707-3796
Mailing Address - Fax:
Practice Address - Street 1:2443 E 1ST ST
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2641
Practice Address - Country:US
Practice Address - Phone:208-707-3796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-2015332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies