Provider Demographics
NPI:1457626277
Name:VAUGHAN, KEVIN ROBERT (MA60240947)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ROBERT
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:MA60240947
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31716 2ND AVE S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-5260
Mailing Address - Country:US
Mailing Address - Phone:253-880-6462
Mailing Address - Fax:
Practice Address - Street 1:31716 2ND AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5260
Practice Address - Country:US
Practice Address - Phone:253-880-6462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60240947225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist