Provider Demographics
NPI:1902122054
Name:ELANTIS LLC
Entity Type:Organization
Organization Name:ELANTIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LANECIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-361-2889
Mailing Address - Street 1:625 N EUCLID AVE
Mailing Address - Street 2:SUITE 521
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1690
Mailing Address - Country:US
Mailing Address - Phone:314-361-2889
Mailing Address - Fax:314-361-1889
Practice Address - Street 1:625 N EUCLID AVE
Practice Address - Street 2:SUITE 521
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-1690
Practice Address - Country:US
Practice Address - Phone:314-361-2889
Practice Address - Fax:314-361-1889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-14
Last Update Date:2010-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0010197Medicaid