Healthcare Provider Details

I. General information

NPI: 1720170608
Provider Name (Legal Business Name): TEIA D. VAUGHN RKT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 RIVERSHYRE DR
EVANS GA
30809-5285
US

IV. Provider business mailing address

1 FREEDOM WAY 294U AUGUSTA VAMC
AUGUSTA GA
30904
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax: 706-731-7165
Mailing address:
  • Phone: 706-733-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number1684
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: