Provider Demographics
NPI:1396186607
Name:VAUGHAN, RICHARD IVAN (BS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:IVAN
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:BS
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 3007
Mailing Address - Street 2:4310 NE KILLINGSWORTH ST
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3007
Mailing Address - Country:US
Mailing Address - Phone:503-535-1150
Mailing Address - Fax:
Practice Address - Street 1:4310 NE KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97208-3007
Practice Address - Country:US
Practice Address - Phone:503-535-1150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children