Provider Demographics
NPI:1659593614
Name:FAIRBANKS, VAUGHN ROGER (DC)
Entity Type:Individual
Prefix:
First Name:VAUGHN
Middle Name:ROGER
Last Name:FAIRBANKS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 SOUTH BEECH STREET
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837
Mailing Address - Country:US
Mailing Address - Phone:509-765-9235
Mailing Address - Fax:509-765-9235
Practice Address - Street 1:414 SOUTH BEECH STREET
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837
Practice Address - Country:US
Practice Address - Phone:509-765-9235
Practice Address - Fax:509-765-9235
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00003350111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA111104OtherSTATE DLI
WAFAIVA0200461618OtherPREMERA BLUE CROSS
U63875Medicare UPIN