Provider Demographics
NPI:1851685150
Name:VAUGHN H. MANCHA, JR., P.C.
Entity Type:Organization
Organization Name:VAUGHN H. MANCHA, JR., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:B
Authorized Official - Last Name:MANCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-300-2573
Mailing Address - Street 1:17328 BURWICK LOOP
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-5243
Mailing Address - Country:US
Mailing Address - Phone:334-300-2573
Mailing Address - Fax:
Practice Address - Street 1:17328 BURWICK LOOP
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-5243
Practice Address - Country:US
Practice Address - Phone:334-300-2511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-03
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14167207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000088588Medicare PIN