Provider Demographics
NPI:1407324379
Name:CHRYSALIS HEALTH OF CALIFORNIA, PC
Entity Type:Organization
Organization Name:CHRYSALIS HEALTH OF CALIFORNIA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TARASOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-809-6796
Mailing Address - Street 1:136 E 76TH ST APT 8F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-2831
Mailing Address - Country:US
Mailing Address - Phone:434-248-7508
Mailing Address - Fax:
Practice Address - Street 1:4470 W SUNSET BLVD # 92709
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6302
Practice Address - Country:US
Practice Address - Phone:424-334-9213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-08
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104823954Medicaid