Provider Demographics
NPI:1164065330
Name:CHASTAIN, KODY LELAN (DC)
Entity Type:Individual
Prefix:DR
First Name:KODY
Middle Name:LELAN
Last Name:CHASTAIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1583 MAIN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-5214
Mailing Address - Country:US
Mailing Address - Phone:479-443-0800
Mailing Address - Fax:
Practice Address - Street 1:1583 MAIN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72704-5214
Practice Address - Country:US
Practice Address - Phone:479-443-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ART16233111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation