MEDICARE: GINA VAUGHN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	227020808	IL

General Provider Information

NPI Number	:	1619432366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA VAUGHN

Provider Business Mailing Address
First Line	:	61 E 21ST ST UNIT 313
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-1714
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2301 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-3487
Country	:	US
Telephone Number	:	773-340-1897
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2019
Last Update Date	:	02/06/2019

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Directions to “ GINA VAUGHN ” Practice Location

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