Healthcare Provider Details

I. General information

NPI: 1861160392
Provider Name (Legal Business Name): JAMES ROBERT VAUGHN III LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/31/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 HIGHLANDER POINT DR
FLOYDS KNOBS IN
47119-8409
US

IV. Provider business mailing address

600 NORTH SHORE DR SUITE 201 #114
JEFFERSONVILLE IN
47136
US

V. Phone/Fax

Practice location:
  • Phone: 812-989-4346
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number262134
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT21706364
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: