Provider Demographics
NPI:1184452187
Name:BLACK, CHASTITY (DC)
Entity type:Individual
Prefix:
First Name:CHASTITY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8101 HACKS CROSS RD STE 110
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-4032
Mailing Address - Country:US
Mailing Address - Phone:901-221-7173
Mailing Address - Fax:662-932-8774
Practice Address - Street 1:1630 GOODMAN RD E STE 3
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9556
Practice Address - Country:US
Practice Address - Phone:901-217-7173
Practice Address - Fax:662-932-8774
Is Sole Proprietor?:No
Enumeration Date:2024-07-23
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN3873111N00000X
MS1398111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor