Provider Demographics
NPI:1407013717
Name:CHRYSALIS ANAPLASTOLOGY & OCULARISTRY INC
Entity Type:Organization
Organization Name:CHRYSALIS ANAPLASTOLOGY & OCULARISTRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SKOWRON
Authorized Official - Suffix:
Authorized Official - Credentials:BCO, BADO, MAMS, BS
Authorized Official - Phone:847-719-2984
Mailing Address - Street 1:23605 N HIGH RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-9048
Mailing Address - Country:US
Mailing Address - Phone:847-719-2984
Mailing Address - Fax:
Practice Address - Street 1:23605 N HIGH RIDGE DR
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-9048
Practice Address - Country:US
Practice Address - Phone:847-719-2984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4112920OtherBC/BS OF TENNESSEE
IL2941551OtherUNITED HEALTH CARE
IL=========OtherBLUE CROSS BLUE SHIELD OF ILLINOIS
IL2941551OtherUNITED HEALTH CARE