Provider Demographics
NPI:1770682692
Name:VAUGHN, BRIAN RANDELL (MPT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:RANDELL
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33217 KENNEDY CT
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-3313
Mailing Address - Country:US
Mailing Address - Phone:619-884-0132
Mailing Address - Fax:951-695-9518
Practice Address - Street 1:33217 KENNEDY CT
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-3313
Practice Address - Country:US
Practice Address - Phone:619-884-0132
Practice Address - Fax:951-695-9518
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23468225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPT23468BMedicare ID - Type Unspecified