Organization
CHRYSALIS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. KENNY PANNELL LCPC (VICE PRESIDENT)
(406) 889-5577
Entity
Organization
Contact information
Practice address
57 TRAILS END RD, EUREKA, MT 59917-9332
(406) 889-5577
(406) 889-5576
Mailing address
57 TRAILS END RD, EUREKA, MT 59917-9332
(406) 889-5577
(406) 889-5576
Taxonomy
Speciality
Code
Description
License number
State
172V00000X
Community Health Worker
—
IL
174400000X
Specialist
Primary
—
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
75473
BLUE CROSS BLUESHIELD
MT
Enumeration date
12/31/2007
Last updated
12/31/2007
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