1134304926 NPI number — CHRYSALIS

Table of content: DR. MOLLY EDWARDS NABORS AUD (NPI 1417830274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134304926 NPI number — CHRYSALIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRYSALIS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134304926
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
57 TRAILS END RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUREKA
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59917-9332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-889-5577
Provider Business Mailing Address Fax Number:
406-889-5576

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
57 TRAILS END RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59917-9332
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-889-5577
Provider Business Practice Location Address Fax Number:
406-889-5576
Provider Enumeration Date:
12/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PANNELL
Authorized Official First Name:
KENNY
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
406-889-5577

Provider Taxonomy Codes

  • Taxonomy code: 172V00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 174400000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 75473 . This is a "BLUE CROSS BLUESHIELD" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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