Healthcare Provider Details

I. General information

NPI: 1134304926
Provider Name (Legal Business Name): CHRYSALIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2007
Last Update Date: 12/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 TRAILS END RD
EUREKA MT
59917-9332
US

IV. Provider business mailing address

57 TRAILS END RD
EUREKA MT
59917-9332
US

V. Phone/Fax

Practice location:
  • Phone: 406-889-5577
  • Fax: 406-889-5576
Mailing address:
  • Phone: 406-889-5577
  • Fax: 406-889-5576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. KENNY PANNELL
Title or Position: VICE PRESIDENT
Credential: LCPC
Phone: 406-889-5577