Healthcare Provider Details

I. General information

NPI: 1386018984
Provider Name (Legal Business Name): STEPHEN LACKY CHASTAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 SE COMMUNITY DR
STUART FL
34997-6420
US

IV. Provider business mailing address

9611 N US HIGHWAY 1 #166
SEBASTIAN FL
32958-6363
US

V. Phone/Fax

Practice location:
  • Phone: 772-324-3901
  • Fax: 772-324-3019
Mailing address:
  • Phone: 772-581-3990
  • Fax: 772-581-3991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME114042
License Number StateFL

VIII. Authorized Official

Name: REGINA MARSHALL
Title or Position: BILLING MANAGER
Credential:
Phone: 772-581-3991