Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NR0400X | Rehabilitation Chiropractor | T16233 | AR |
NPI | 1164065330 |
---|---|
Provider Name | Dr. Kody Lelan Chastain |
First Address | Fayetteville, AR 72704-5214 |
Second Address | Fayetteville, AR 72704-5214 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/10/2019 |
Last Update Date | 21/10/2019 |