Healthcare Provider Details

I. General information

NPI: 1407324379
Provider Name (Legal Business Name): CHRYSALIS HEALTH OF CALIFORNIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4470 W SUNSET BLVD # 92709
LOS ANGELES CA
90027-6302
US

IV. Provider business mailing address

136 E 76TH ST APT 8F
NEW YORK NY
10021-2831
US

V. Phone/Fax

Practice location:
  • Phone: 424-334-9213
  • Fax:
Mailing address:
  • Phone: 434-248-7508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: MARINA TARASOVA
Title or Position: COO
Credential:
Phone: 847-809-6796