Provider Demographics
NPI:1659365898
Name:VAUGHAN, CLARK K (PT)
Entity Type:Individual
Prefix:
First Name:CLARK
Middle Name:K
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-6018
Mailing Address - Country:US
Mailing Address - Phone:304-545-2152
Mailing Address - Fax:304-255-7120
Practice Address - Street 1:109 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6018
Practice Address - Country:US
Practice Address - Phone:304-545-2152
Practice Address - Fax:304-255-7120
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01221225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV157476000Medicaid
VA4139091Medicare ID - Type Unspecified
VA4139092Medicare ID - Type Unspecified