Provider Demographics
NPI:1124256102
Name:CHASTAIN, CORY
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:CHASTAIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 299
Mailing Address - Street 2:
Mailing Address - City:HOXIE
Mailing Address - State:AR
Mailing Address - Zip Code:72433-0299
Mailing Address - Country:US
Mailing Address - Phone:870-886-1333
Mailing Address - Fax:870-886-1334
Practice Address - Street 1:503 SE LINDSEY ST
Practice Address - Street 2:
Practice Address - City:HOXIE
Practice Address - State:AR
Practice Address - Zip Code:72433-2224
Practice Address - Country:US
Practice Address - Phone:870-886-1333
Practice Address - Fax:870-886-1334
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator