Healthcare Provider Details

I. General information

NPI: 1649565235
Provider Name (Legal Business Name): JOSE M VAUGHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

456 ELM AVE
LONG BEACH CA
90802-2426
US

IV. Provider business mailing address

11502 LINDALE ST
NORWALK CA
90650-4719
US

V. Phone/Fax

Practice location:
  • Phone: 562-285-1330
  • Fax:
Mailing address:
  • Phone: 562-547-2757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: