Provider Demographics
NPI:1033470786
Name:VAUGHT, DAVID DARYL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:DARYL
Last Name:VAUGHT
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:RR 5 BOX 108C
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9353
Mailing Address - Country:US
Mailing Address - Phone:304-629-5409
Mailing Address - Fax:
Practice Address - Street 1:RR 5 BOX 108-C
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330
Practice Address - Country:US
Practice Address - Phone:304-629-5409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0001061314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility