Basic Information
| Provider Information | |||||||||
| NPI: | 1073811196 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRYSALIS TEXAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 531 E 770 N | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840974102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016554950 | ||||||||
| FaxNumber: | 8016554954 | ||||||||
| Practice Location | |||||||||
| Address1: | 531 E 770 N | ||||||||
| Address2: | |||||||||
| City: | OREM | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840974102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016554950 | ||||||||
| FaxNumber: | 8016554954 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2011 | ||||||||
| LastUpdateDate: | 03/14/2011 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTENSEN | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8013604672 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHRYSALIS UTAH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | TX | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
No ID Information.