Provider Demographics
NPI:1821032335
Name:VAUGHAN, CONRAD SCOTT (DC)
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:SCOTT
Last Name:VAUGHAN
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 1:4307 BALL CAMP PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37921-3313
Mailing Address - Country:US
Mailing Address - Phone:865-524-1234
Mailing Address - Fax:865-524-2169
Practice Address - Street 1:312 PROSPERITY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4721
Practice Address - Country:US
Practice Address - Phone:865-691-3155
Practice Address - Fax:865-694-8093
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC1753111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN003156082OtherBLUE CROSS BLUE SHIELD
TN621395243OtherEMPLOYER TIN
TN003156082OtherBLUE CROSS BLUE SHIELD
TN3971174Medicare ID - Type Unspecified