Provider Demographics
NPI:1639231103
Name:CHASTAIN, KIM E (PT, OCS)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:E
Last Name:CHASTAIN
Suffix:
Gender:F
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 ACWORTH DUE WEST RD NW
Mailing Address - Street 2:SUITE 310
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1001
Mailing Address - Country:US
Mailing Address - Phone:770-974-7494
Mailing Address - Fax:770-974-9141
Practice Address - Street 1:3450 ACWORTH DUE WEST RD NW
Practice Address - Street 2:SUITE 310
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1001
Practice Address - Country:US
Practice Address - Phone:770-974-7494
Practice Address - Fax:770-974-9141
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT003909225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBFGLMedicare PIN
116838Medicare ID - Type Unspecified