MEDICARE: CHRYSALIS NEVADA INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	385H00000X	Respite Care

General Provider Information

NPI Number	:	1134581093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRYSALIS NEVADA INC

Provider Business Mailing Address
First Line	:	1443 W 800 N
Second Line	:	SUITE 103
City	:	OREM
State	:	UT
Zip	:	84057-2875
Country	:	US
Telephone Number	:	801-655-4950
Fax Number	:

Provider Business Practice Location Address
First Line	:	3460 W CHEYENNE AVE
Second Line	:	SUITE 100
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-8241
Country	:	US
Telephone Number	:	702-227-7300
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARC ROBERT CHRISTENSEN
Credential	:
Telephone Number	:	801-655-4950

Provider Enumeration Date	:	03/22/2016
Last Update Date	:	03/22/2016

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