Healthcare Provider Details

I. General information

NPI: 1093605206
Provider Name (Legal Business Name): CHRYSALIS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 W PRAIRIE AVE STE 3
COEUR D ALENE ID
83815-9401
US

IV. Provider business mailing address

280 W PRAIRIE AVE STE 3
COEUR D ALENE ID
83815-9401
US

V. Phone/Fax

Practice location:
  • Phone: 208-707-2770
  • Fax: 208-770-2771
Mailing address:
  • Phone: 208-707-2770
  • Fax: 208-770-2771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERRI K JOHNSON
Title or Position: CEO
Credential:
Phone: 208-770-2770