=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407013717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRYSALIS ANAPLASTOLOGY & OCULARISTRY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2008
-----------------------------------------------------
Last Update Date | 08/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23605 N HIGH RIDGE DR
-----------------------------------------------------
City | LAKE ZURICH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60047-9048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-719-2984
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23605 N HIGH RIDGE DR
-----------------------------------------------------
City | LAKE ZURICH
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60047-9048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-719-2984
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MISS LISA MARIE SKOWRON
-----------------------------------------------------
Credential | BCO, BADO, MAMS, BS
-----------------------------------------------------
Telephone | 847-719-2984
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------